- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,547.84 / $2,547.84 / $2,660.30
| Facility | | $2,547.84 | $2,547.84 | $2,660.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,060.56 / $2,485.50 / $3,075.78
| Professional | | $2,060.56 | $2,485.50 | $3,075.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,338.83 / $4,053.66 / $4,053.66
| Facility | | $2,338.83 | $4,053.66 | $4,053.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,930.89 / $2,733.10 / $2,877.28
| Professional | | $1,930.89 | $2,733.10 | $2,877.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,569.13 / $2,569.13 / $2,569.13
| Facility | | $2,569.13 | $2,569.13 | $2,569.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $310.38 / $2,183.76 / $4,848.75
| Professional | | $310.38 | $2,183.76 | $4,848.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $147.80 / $200.63 / $417.98
| Professional | | $147.80 | $200.63 | $417.98 |