- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,728.94 / $1,732.43 / $2,174.90
| Facility | | $1,728.94 | $1,732.43 | $2,174.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,478.33 / $1,732.43 / $2,564.69
| Professional | | $1,478.33 | $1,732.43 | $2,564.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,345.13 / $3,580.97 / $6,690.26
| Facility | | $3,345.13 | $3,580.97 | $6,690.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,838.86 / $1,838.86 / $2,682.61
| Professional | | $1,838.86 | $1,838.86 | $2,682.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,217.07 / $2,217.07 / $2,217.07
| Facility | | $2,217.07 | $2,217.07 | $2,217.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,618.46 / $2,169.42 / $2,363.51
| Professional | | $1,618.46 | $2,169.42 | $2,363.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,176.86 / $2,018.42 / $2,301.38
| Facility | | $1,176.86 | $2,018.42 | $2,301.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,279.26 / $1,718.92 / $2,422.51
| Professional | | $1,279.26 | $1,718.92 | $2,422.51 |