- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,945.38 / $1,982.08 / $2,447.15
| Facility | | $1,945.38 | $1,982.08 | $2,447.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,655.33 / $2,069.05 / $2,836.44
| Professional | | $1,655.33 | $2,069.05 | $2,836.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,763.92 / $4,029.24 / $7,527.84
| Facility | | $3,763.92 | $4,029.24 | $7,527.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,048.37 / $2,048.37 / $3,043.60
| Professional | | $2,048.37 | $2,048.37 | $3,043.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,326.75 / $2,326.75 / $2,326.75
| Facility | | $2,326.75 | $2,326.75 | $2,326.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.53 / $2,326.75 / $2,480.44
| Professional | | $1,698.53 | $2,326.75 | $2,480.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,422.48 / $1,877.77 / $2,828.58
| Professional | | $1,422.48 | $1,877.77 | $2,828.58 |