- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,836.88 / $1,860.40 / $2,232.48
| Facility | | $1,836.88 | $1,860.40 | $2,232.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,487.61 / $1,844.39 / $2,593.39
| Professional | | $1,487.61 | $1,844.39 | $2,593.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,140.71 / $3,558.14 / $7,029.85
| Facility | | $3,140.71 | $3,558.14 | $7,029.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,871.77 / $1,876.10 / $2,700.97
| Professional | | $1,871.77 | $1,876.10 | $2,700.97 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,571.77 / $2,571.77 / $2,571.77
| Facility | | $2,571.77 | $2,571.77 | $2,571.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,877.39 / $2,463.75 / $2,648.92
| Professional | | $1,877.39 | $2,463.75 | $2,648.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,276.70 / $1,738.33 / $2,429.80
| Professional | | $1,276.70 | $1,738.33 | $2,429.80 |