- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,888.58 / $1,892.41 / $2,375.69
| Facility | | $1,888.58 | $1,892.41 | $2,375.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,614.85 / $1,927.12 / $2,801.54
| Professional | | $1,614.85 | $1,927.12 | $2,801.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,653.99 / $3,911.59 / $7,307.98
| Facility | | $3,653.99 | $3,911.59 | $7,307.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,078.94 / $2,249.31 / $3,050.38
| Professional | | $2,078.94 | $2,249.31 | $3,050.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,264.80 / $2,264.80 / $2,264.80
| Facility | | $2,264.80 | $2,264.80 | $2,264.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,653.30 / $2,264.80 / $2,414.39
| Professional | | $1,653.30 | $2,264.80 | $2,414.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,391.17 / $1,877.66 / $2,638.09
| Professional | | $1,391.17 | $1,877.66 | $2,638.09 |