- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,215.26 / $2,237.86 / $2,838.49
| Facility | | $2,215.26 | $2,237.86 | $2,838.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,892.27 / $2,258.21 / $3,282.84
| Professional | | $1,892.27 | $2,258.21 | $3,282.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,281.76 / $4,583.66 / $8,563.54
| Facility | | $4,281.76 | $4,583.66 | $8,563.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,371.39 / $2,635.75 / $3,545.68
| Professional | | $2,371.39 | $2,635.75 | $3,545.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,448.80 / $2,448.80 / $2,448.80
| Facility | | $2,448.80 | $2,448.80 | $2,448.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,787.62 / $2,448.80 / $2,871.59
| Professional | | $1,787.62 | $2,448.80 | $2,871.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,670.20 / $2,200.44 / $3,100.81
| Professional | | $1,670.20 | $2,200.44 | $3,100.81 |