- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,182.02 / $1,182.02 / $1,445.41
| Facility | | $1,182.02 | $1,182.02 | $1,445.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $915.98 / $1,230.68 / $1,773.02
| Professional | | $915.98 | $1,230.68 | $1,773.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,051.13 / $2,456.98 / $4,401.35
| Facility | | $2,051.13 | $2,456.98 | $4,401.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,247.33 / $1,253.11 / $2,109.21
| Professional | | $1,247.33 | $1,253.11 | $2,109.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,637.27 / $1,637.27 / $1,637.27
| Facility | | $1,637.27 | $1,637.27 | $1,637.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,195.21 / $1,602.08 / $1,686.39
| Professional | | $1,195.21 | $1,602.08 | $1,686.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,366.91 / $1,366.91 / $1,366.91
| Facility | | $1,366.91 | $1,366.91 | $1,366.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $852.74 / $1,171.38 / $1,705.48
| Professional | | $852.74 | $1,171.38 | $1,705.48 |