- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,398.24 / $1,428.74 / $1,834.72
| Facility | | $1,398.24 | $1,428.74 | $1,834.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,108.67 / $1,471.56 / $2,059.61
| Professional | | $1,108.67 | $1,471.56 | $2,059.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,521.92 / $3,213.50 / $5,419.93
| Facility | | $2,521.92 | $3,213.50 | $5,419.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,484.70 / $1,484.70 / $2,463.10
| Professional | | $1,484.70 | $1,484.70 | $2,463.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,787.17 / $1,787.17 / $1,787.17
| Facility | | $1,787.17 | $1,787.17 | $1,787.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,304.63 / $1,304.63 / $3,295.57
| Professional | | $1,304.63 | $1,304.63 | $3,295.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,448.21 / $1,448.21 / $1,448.21
| Facility | | $1,448.21 | $1,448.21 | $1,448.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,068.51 / $1,473.04 / $2,037.24
| Professional | | $1,068.51 | $1,473.04 | $2,037.24 |