- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,563.35 / $1,568.16 / $1,881.79
| Facility | | $1,563.35 | $1,568.16 | $1,881.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,245.89 / $1,625.88 / $2,267.02
| Professional | | $1,245.89 | $1,625.88 | $2,267.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,785.04 / $3,306.33 / $5,978.65
| Facility | | $2,785.04 | $3,306.33 | $5,978.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,683.15 / $1,693.61 / $2,442.69
| Professional | | $1,683.15 | $1,693.61 | $2,442.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,125.02 / $2,125.02 / $2,125.02
| Facility | | $2,125.02 | $2,125.02 | $2,125.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,551.26 / $2,079.36 / $2,188.77
| Professional | | $1,551.26 | $2,079.36 | $2,188.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,157.85 / $1,506.27 / $2,194.94
| Professional | | $1,157.85 | $1,506.27 | $2,194.94 |