- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,924.81 / $1,924.81 / $2,033.08
| Facility | | $1,924.81 | $1,924.81 | $2,033.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,355.39 / $1,822.43 / $2,326.51
| Professional | | $1,355.39 | $1,822.43 | $2,326.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,511.35 / $2,796.08 / $2,796.08
| Facility | | $2,511.35 | $2,796.08 | $2,796.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,897.49 / $2,260.04 / $2,279.06
| Professional | | $1,897.49 | $2,260.04 | $2,279.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,406.76 / $1,406.76 / $1,406.76
| Facility | | $1,406.76 | $1,406.76 | $1,406.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $229.74 / $1,406.76 / $2,566.63
| Professional | | $229.74 | $1,406.76 | $2,566.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,011.49 / $1,302.91 / $2,171.51
| Professional | | $1,011.49 | $1,302.91 | $2,171.51 |