- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,879.32 / $1,928.18 / $2,500.13
| Facility | | $1,879.32 | $1,928.18 | $2,500.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,464.79 / $1,946.81 / $2,762.92
| Professional | | $1,464.79 | $1,946.81 | $2,762.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,274.36 / $4,116.46 / $7,187.00
| Facility | | $3,274.36 | $4,116.46 | $7,187.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,989.40 / $2,000.39 / $3,086.48
| Professional | | $1,989.40 | $2,000.39 | $3,086.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,694.60 / $2,694.60 / $2,694.60
| Facility | | $2,694.60 | $2,694.60 | $2,694.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,967.06 / $1,967.06 / $4,050.81
| Professional | | $1,967.06 | $1,967.06 | $4,050.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,379.94 / $1,887.83 / $2,590.79
| Professional | | $1,379.94 | $1,887.83 | $2,590.79 |