- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,105.90 / $2,197.36 / $2,566.88
| Facility | | $2,105.90 | $2,197.36 | $2,566.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,972.42 / $2,175.67 / $3,514.08
| Professional | | $1,972.42 | $2,175.67 | $3,514.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,944.84 / $4,744.16 / $7,889.68
| Facility | | $3,944.84 | $4,744.16 | $7,889.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,517.37 / $2,859.80 / $3,760.77
| Professional | | $2,517.37 | $2,859.80 | $3,760.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,481.10 / $2,481.10 / $2,481.10
| Facility | | $2,481.10 | $2,481.10 | $2,481.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,811.20 / $2,481.10 / $2,909.47
| Professional | | $1,811.20 | $2,481.10 | $2,909.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,516.35 / $2,600.65 / $2,965.23
| Facility | | $1,516.35 | $2,600.65 | $2,965.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,640.03 / $2,151.64 / $3,142.44
| Professional | | $1,640.03 | $2,151.64 | $3,142.44 |