- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,347.87 / $2,361.56 / $3,082.16
| Facility | | $2,347.87 | $2,361.56 | $3,082.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,942.72 / $2,372.87 / $3,168.67
| Professional | | $1,942.72 | $2,372.87 | $3,168.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,214.02 / $4,561.55 / $8,822.31
| Facility | | $4,214.02 | $4,561.55 | $8,822.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,554.69 / $2,578.42 / $3,480.86
| Professional | | $2,554.69 | $2,578.42 | $3,480.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,741.63 / $2,741.63 / $2,741.63
| Facility | | $2,741.63 | $2,741.63 | $2,741.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,001.39 / $2,741.63 / $2,855.60
| Professional | | $2,001.39 | $2,741.63 | $2,855.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,751.94 / $2,250.64 / $3,334.28
| Professional | | $1,751.94 | $2,250.64 | $3,334.28 |