- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,977.04 / $2,108.17 / $3,288.74
| Facility | | $1,977.04 | $2,108.17 | $3,288.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.69 / $1,819.69 / $2,635.21
| Professional | | $1,819.69 | $1,819.69 | $2,635.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,556.17 / $1,556.17 / $1,556.17
| Facility | | $1,556.17 | $1,556.17 | $1,556.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,058.20 / $1,556.17 / $2,100.83
| Professional | | $1,058.20 | $1,556.17 | $2,100.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,549.86 / $2,704.74 / $3,380.93
| Professional | | $2,549.86 | $2,704.74 | $3,380.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,108.17 / $2,108.17 / $3,873.76
| Facility | | $2,108.17 | $2,108.17 | $3,873.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,108.17 / $2,130.36 / $2,662.95
| Professional | | $2,108.17 | $2,130.36 | $2,662.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $932.03 / $1,331.48 / $1,420.24
| Professional | | $932.03 | $1,331.48 | $1,420.24 |