- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,831.89 / $1,866.89 / $2,249.88
| Facility | | $1,831.89 | $1,866.89 | $2,249.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,554.79 / $1,902.35 / $2,620.19
| Professional | | $1,554.79 | $1,902.35 | $2,620.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,228.39 / $3,931.19 / $6,736.20
| Facility | | $3,228.39 | $3,931.19 | $6,736.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,963.22 / $1,966.25 / $2,663.14
| Professional | | $1,963.22 | $1,966.25 | $2,663.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,017.28 / $2,017.28 / $2,227.25
| Facility | | $2,017.28 | $2,017.28 | $2,227.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,472.61 / $2,017.28 / $2,364.04
| Professional | | $1,472.61 | $2,017.28 | $2,364.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,333.05 / $1,694.79 / $2,684.34
| Professional | | $1,333.05 | $1,694.79 | $2,684.34 |