- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,861.13 / $2,884.01 / $4,643.39
| Facility | | $1,861.13 | $2,884.01 | $4,643.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,828.72 / $1,870.43 / $2,377.33
| Professional | | $1,828.72 | $1,870.43 | $2,377.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,855.87 / $3,042.98 / $5,842.76
| Facility | | $1,855.87 | $3,042.98 | $5,842.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,828.72 / $1,828.72 / $1,865.29
| Professional | | $1,828.72 | $1,828.72 | $1,865.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,725.20 / $1,828.71 / $1,828.71
| Facility | | $1,725.20 | $1,828.71 | $1,828.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,828.71 / $1,828.71 / $1,828.71
| Professional | | $1,828.71 | $1,828.71 | $1,828.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,828.72 / $1,828.72 / $2,380.98
| Professional | | $1,828.72 | $1,828.72 | $2,380.98 |