- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,392.96 / $1,395.78 / $1,752.28
| Facility | | $1,392.96 | $1,395.78 | $1,752.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.74 / $1,395.78 / $2,066.29
| Professional | | $1,202.74 | $1,395.78 | $2,066.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,695.08 / $2,885.13 / $5,390.16
| Facility | | $2,695.08 | $2,885.13 | $5,390.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,487.71 / $1,487.71 / $2,224.09
| Professional | | $1,487.71 | $1,487.71 | $2,224.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,786.24 / $1,786.24 / $1,786.24
| Facility | | $1,786.24 | $1,786.24 | $1,786.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,303.96 / $1,669.48 / $1,839.83
| Professional | | $1,303.96 | $1,669.48 | $1,839.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,051.29 / $1,385.01 / $1,951.75
| Professional | | $1,051.29 | $1,385.01 | $1,951.75 |