- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,920.76 / $1,924.66 / $2,416.17
| Facility | | $1,920.76 | $1,924.66 | $2,416.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,642.36 / $1,959.97 / $2,849.28
| Professional | | $1,642.36 | $1,959.97 | $2,849.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,716.28 / $3,978.24 / $7,432.56
| Facility | | $3,716.28 | $3,978.24 | $7,432.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,055.73 / $2,068.50 / $3,005.08
| Professional | | $2,055.73 | $2,068.50 | $3,005.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,463.07 / $2,463.07 / $2,463.07
| Facility | | $2,463.07 | $2,463.07 | $2,463.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,798.04 / $2,410.14 / $2,625.75
| Professional | | $1,798.04 | $2,410.14 | $2,625.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,442.50 / $1,909.64 / $2,691.29
| Professional | | $1,442.50 | $1,909.64 | $2,691.29 |