- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,366.46 / $2,366.46 / $2,411.09
| Facility | | $2,366.46 | $2,366.46 | $2,411.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,803.02 / $2,303.35 / $2,852.00
| Professional | | $1,803.02 | $2,303.35 | $2,852.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,912.80 / $3,210.53 / $3,210.53
| Facility | | $1,912.80 | $3,210.53 | $3,210.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,122.10 / $2,583.84 / $2,835.80
| Professional | | $2,122.10 | $2,583.84 | $2,835.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,416.31 / $2,416.31 / $2,416.31
| Facility | | $2,416.31 | $2,416.31 | $2,416.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $288.01 / $2,416.31 / $2,488.82
| Professional | | $288.01 | $2,416.31 | $2,488.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,068.88 / $1,458.04 / $2,442.27
| Professional | | $1,068.88 | $1,458.04 | $2,442.27 |