- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,869.01 / $1,893.71 / $2,185.96
| Facility | | $1,869.01 | $1,893.71 | $2,185.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,491.67 / $1,894.51 / $2,565.67
| Professional | | $1,491.67 | $1,894.51 | $2,565.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,396.97 / $3,987.57 / $6,932.70
| Facility | | $3,396.97 | $3,987.57 | $6,932.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,925.05 / $1,932.42 / $2,951.38
| Professional | | $1,925.05 | $1,932.42 | $2,951.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,476.09 / $2,476.09 / $2,476.09
| Facility | | $2,476.09 | $2,476.09 | $2,476.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,807.55 / $2,476.09 / $2,568.48
| Professional | | $1,807.55 | $2,476.09 | $2,568.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,364.62 / $1,808.05 / $2,557.56
| Professional | | $1,364.62 | $1,808.05 | $2,557.56 |