- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,231.11 / $2,235.63 / $2,806.62
| Facility | | $2,231.11 | $2,235.63 | $2,806.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,926.49 / $2,276.67 / $3,309.66
| Professional | | $1,926.49 | $2,276.67 | $3,309.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,316.77 / $4,621.10 / $8,633.54
| Facility | | $4,316.77 | $4,621.10 | $8,633.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,440.28 / $2,699.26 / $3,644.00
| Professional | | $2,440.28 | $2,699.26 | $3,644.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,060.59 / $3,060.59 / $3,060.59
| Facility | | $3,060.59 | $3,060.59 | $3,060.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,234.23 / $2,234.23 / $4,694.82
| Professional | | $2,234.23 | $2,234.23 | $4,694.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,683.86 / $2,206.46 / $3,177.03
| Professional | | $1,683.86 | $2,206.46 | $3,177.03 |