- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,855.48 / $1,864.12 / $2,140.94
| Facility | | $1,855.48 | $1,864.12 | $2,140.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,534.45 / $1,855.48 / $2,529.48
| Professional | | $1,534.45 | $1,855.48 | $2,529.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,289.43 / $3,698.48 / $6,822.94
| Facility | | $3,289.43 | $3,698.48 | $6,822.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,896.54 / $1,929.14 / $2,776.65
| Professional | | $1,896.54 | $1,929.14 | $2,776.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,425.11 / $2,425.11 / $2,425.11
| Facility | | $2,425.11 | $2,425.11 | $2,425.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,770.33 / $2,373.00 / $2,497.86
| Professional | | $1,770.33 | $2,373.00 | $2,497.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,312.80 / $1,718.69 / $2,498.07
| Professional | | $1,312.80 | $1,718.69 | $2,498.07 |