- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,056.79 / $2,096.34 / $2,665.57
| Facility | | $2,056.79 | $2,096.34 | $2,665.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,652.52 / $2,124.94 / $3,076.85
| Professional | | $1,652.52 | $2,124.94 | $3,076.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,893.60 / $4,722.62 / $7,813.79
| Facility | | $3,893.60 | $4,722.62 | $7,813.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,260.71 / $2,260.71 / $3,638.31
| Professional | | $2,260.71 | $2,260.71 | $3,638.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,717.61 / $2,717.61 / $2,717.61
| Facility | | $2,717.61 | $2,717.61 | $2,717.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,983.86 / $2,717.61 / $2,844.80
| Professional | | $1,983.86 | $2,717.61 | $2,844.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,611.81 / $2,085.30 / $2,927.43
| Professional | | $1,611.81 | $2,085.30 | $2,927.43 |