- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,866.61 / $1,940.57 / $2,328.67
| Facility | | $1,866.61 | $1,940.57 | $2,328.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,483.01 / $1,989.05 / $2,786.69
| Professional | | $1,483.01 | $1,989.05 | $2,786.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,315.08 / $4,420.10 / $7,421.25
| Facility | | $3,315.08 | $4,420.10 | $7,421.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,015.94 / $2,025.27 / $2,959.83
| Professional | | $2,015.94 | $2,025.27 | $2,959.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,637.76 / $2,637.76 / $2,637.76
| Facility | | $2,637.76 | $2,637.76 | $2,637.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,925.56 / $2,623.38 / $2,716.89
| Professional | | $1,925.56 | $2,623.38 | $2,716.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,423.60 / $1,823.10 / $2,724.54
| Professional | | $1,423.60 | $1,823.10 | $2,724.54 |