- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,011.81 / $2,037.55 / $2,456.51
| Facility | | $2,011.81 | $2,037.55 | $2,456.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,608.47 / $2,037.91 / $2,745.72
| Professional | | $1,608.47 | $2,037.91 | $2,745.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,503.09 / $4,189.25 / $6,926.04
| Facility | | $3,503.09 | $4,189.25 | $6,926.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,063.02 / $2,072.57 / $3,145.10
| Professional | | $2,063.02 | $2,072.57 | $3,145.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,782.58 / $2,782.58 / $2,782.58
| Facility | | $2,782.58 | $2,782.58 | $2,782.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,031.28 / $2,031.28 / $4,412.45
| Professional | | $2,031.28 | $2,031.28 | $4,412.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,410.40 / $1,927.73 / $2,765.59
| Professional | | $1,410.40 | $1,927.73 | $2,765.59 |