- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,901.83 / $1,905.69 / $2,392.40
| Facility | | $1,901.83 | $1,905.69 | $2,392.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,635.08 / $1,905.69 / $2,821.17
| Professional | | $1,635.08 | $1,905.69 | $2,821.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,679.64 / $3,939.10 / $7,484.46
| Facility | | $3,679.64 | $3,939.10 | $7,484.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,035.44 / $2,060.88 / $2,950.18
| Professional | | $2,035.44 | $2,060.88 | $2,950.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,677.88 / $2,677.88 / $2,677.88
| Facility | | $2,677.88 | $2,677.88 | $2,677.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,954.85 / $2,386.38 / $2,854.76
| Professional | | $1,954.85 | $2,386.38 | $2,854.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,428.30 / $1,891.00 / $2,820.42
| Professional | | $1,428.30 | $1,891.00 | $2,820.42 |