- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,058.56 / $2,059.76 / $2,822.50
| Facility | | $2,058.56 | $2,059.76 | $2,822.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,669.97 / $2,086.65 / $3,049.67
| Professional | | $1,669.97 | $2,086.65 | $3,049.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,837.43 / $4,637.52 / $7,674.86
| Facility | | $3,837.43 | $4,637.52 | $7,674.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,224.32 / $2,262.55 / $3,427.56
| Professional | | $2,224.32 | $2,262.55 | $3,427.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,970.85 / $2,970.85 / $2,970.85
| Facility | | $2,970.85 | $2,970.85 | $2,970.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,168.71 / $2,668.63 / $3,167.07
| Professional | | $2,168.71 | $2,668.63 | $3,167.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,668.24 / $2,001.59 / $3,093.20
| Professional | | $1,668.24 | $2,001.59 | $3,093.20 |