- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,521.80 / $1,561.53 / $1,873.83
| Facility | | $1,521.80 | $1,561.53 | $1,873.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,215.34 / $1,607.73 / $2,346.31
| Professional | | $1,215.34 | $1,607.73 | $2,346.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,702.68 / $3,114.30 / $5,585.46
| Facility | | $2,702.68 | $3,114.30 | $5,585.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,619.41 / $1,619.41 / $2,539.40
| Professional | | $1,619.41 | $1,619.41 | $2,539.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,283.76 / $2,283.76 / $2,283.76
| Facility | | $2,283.76 | $2,283.76 | $2,283.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,667.14 / $1,699.96 / $2,434.60
| Professional | | $1,667.14 | $1,699.96 | $2,434.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,114.00 / $1,444.70 / $2,192.38
| Professional | | $1,114.00 | $1,444.70 | $2,192.38 |