- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,293.78 / $2,445.92 / $3,815.64
| Facility | | $2,293.78 | $2,445.92 | $3,815.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,059.71 / $2,188.44 / $3,861.97
| Professional | | $2,059.71 | $2,188.44 | $3,861.97 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,805.48 / $1,805.48 / $1,805.48
| Facility | | $1,805.48 | $1,805.48 | $1,805.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,715.21 / $1,805.48 / $2,008.23
| Professional | | $1,715.21 | $1,805.48 | $2,008.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,137.97 / $3,137.97 / $3,922.46
| Professional | | $3,137.97 | $3,137.97 | $3,922.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,445.92 / $2,445.92 / $4,494.38
| Facility | | $2,445.92 | $2,445.92 | $4,494.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,471.66 / $2,471.66 / $3,089.58
| Professional | | $2,471.66 | $2,471.66 | $3,089.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,081.34 / $1,544.79 / $2,574.65
| Professional | | $1,081.34 | $1,544.79 | $2,574.65 |