- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,877.28 / $2,080.50 / $2,090.91
| Facility | | $1,877.28 | $2,080.50 | $2,090.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,630.75 / $2,052.47 / $2,681.37
| Professional | | $1,630.75 | $2,052.47 | $2,681.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,751.98 / $1,751.98 / $3,381.32
| Facility | | $1,751.98 | $1,751.98 | $3,381.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,751.98 / $1,880.67 / $2,945.13
| Professional | | $1,751.98 | $1,880.67 | $2,945.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,576.44 / $2,576.44 / $2,576.44
| Facility | | $2,576.44 | $2,576.44 | $2,576.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $192.51 / $1,472.88 / $3,637.50
| Professional | | $192.51 | $1,472.88 | $3,637.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $143.24 / $271.88 / $2,334.26
| Professional | | $143.24 | $271.88 | $2,334.26 |