- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,261.73 / $2,266.31 / $2,845.12
| Facility | | $2,261.73 | $2,266.31 | $2,845.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,933.91 / $2,307.87 / $3,355.07
| Professional | | $1,933.91 | $2,307.87 | $3,355.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,375.91 / $4,684.49 / $8,751.82
| Facility | | $4,375.91 | $4,684.49 | $8,751.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,555.87 / $2,693.73 / $3,623.00
| Professional | | $2,555.87 | $2,693.73 | $3,623.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,502.67 / $2,502.67 / $2,528.88
| Facility | | $2,502.67 | $2,502.67 | $2,528.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,826.95 / $2,502.67 / $2,710.75
| Professional | | $1,826.95 | $2,502.67 | $2,710.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,666.02 / $2,248.64 / $3,169.03
| Professional | | $1,666.02 | $2,248.64 | $3,169.03 |