- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,847.62 / $1,855.26 / $2,333.98
| Facility | | $1,847.62 | $1,855.26 | $2,333.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,484.69 / $1,936.20 / $2,782.90
| Professional | | $1,484.69 | $1,936.20 | $2,782.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,310.57 / $3,915.54 / $7,088.98
| Facility | | $3,310.57 | $3,915.54 | $7,088.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,988.34 / $1,988.34 / $2,939.00
| Professional | | $1,988.34 | $1,988.34 | $2,939.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,482.86 / $2,482.86 / $2,482.86
| Facility | | $2,482.86 | $2,482.86 | $2,482.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,812.49 / $2,482.86 / $2,646.85
| Professional | | $1,812.49 | $2,482.86 | $2,646.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,272.54 / $2,182.50 / $2,488.46
| Facility | | $1,272.54 | $2,182.50 | $2,488.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,376.34 / $1,825.88 / $2,619.00
| Professional | | $1,376.34 | $1,825.88 | $2,619.00 |