- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,978.33 / $1,978.33 / $2,327.83
| Facility | | $1,978.33 | $1,978.33 | $2,327.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,677.67 / $1,980.39 / $2,879.47
| Professional | | $1,677.67 | $1,980.39 | $2,879.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,532.74 / $4,219.84 / $7,065.48
| Facility | | $3,532.74 | $4,219.84 | $7,065.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,068.73 / $2,151.62 / $2,953.21
| Professional | | $2,068.73 | $2,151.62 | $2,953.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,507.59 / $2,507.59 / $2,507.59
| Facility | | $2,507.59 | $2,507.59 | $2,507.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,830.54 / $2,507.59 / $2,582.82
| Professional | | $1,830.54 | $2,507.59 | $2,582.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,403.49 / $1,853.17 / $2,797.23
| Professional | | $1,403.49 | $1,853.17 | $2,797.23 |