- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,476.20 / $1,543.60 / $1,543.60
| Facility | | $1,476.20 | $1,543.60 | $1,543.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,365.29 / $1,497.09 / $1,734.32
| Professional | | $1,365.29 | $1,497.09 | $1,734.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,007.00 / $1,342.67 / $1,808.84
| Professional | | $1,007.00 | $1,342.67 | $1,808.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,040.90 / $2,083.86 / $2,546.94
| Facility | | $2,040.90 | $2,083.86 | $2,546.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,696.53 / $2,083.86 / $2,604.83
| Professional | | $1,696.53 | $2,083.86 | $2,604.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,506.47 / $1,772.32 / $1,977.00
| Professional | | $1,506.47 | $1,772.32 | $1,977.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,342.67 / $1,342.67 / $1,342.67
| Professional | | $1,342.67 | $1,342.67 | $1,342.67 |