- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,047.56 / $2,049.82 / $2,575.92
| Facility | | $2,047.56 | $2,049.82 | $2,575.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,788.48 / $2,091.67 / $3,040.70
| Professional | | $1,788.48 | $2,091.67 | $3,040.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,965.99 / $4,241.24 / $8,091.16
| Facility | | $3,965.99 | $4,241.24 | $8,091.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,207.84 / $2,207.84 / $3,198.61
| Professional | | $2,207.84 | $2,207.84 | $3,198.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,282.71 / $2,282.71 / $2,282.71
| Facility | | $2,282.71 | $2,282.71 | $2,282.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,666.39 / $1,666.39 / $4,299.87
| Professional | | $1,666.39 | $1,666.39 | $4,299.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,982.23 / $1,982.23 / $1,982.23
| Facility | | $1,982.23 | $1,982.23 | $1,982.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,565.91 / $2,038.15 / $2,974.49
| Professional | | $1,565.91 | $2,038.15 | $2,974.49 |