- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,451.36 / $2,454.92 / $5,551.97
| Facility | | $2,451.36 | $2,454.92 | $5,551.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,454.92 / $2,454.92 / $2,454.92
| Professional | | $2,454.92 | $2,454.92 | $2,454.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,419.07 / $2,955.48 / $3,140.88
| Facility | | $2,419.07 | $2,955.48 | $3,140.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,116.32 / $2,116.32 / $2,116.32
| Professional | | $2,116.32 | $2,116.32 | $2,116.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,088.85 / $4,173.00 / $5,990.94
| Facility | | $3,088.85 | $4,173.00 | $5,990.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,010.50 / $2,116.32 / $2,116.32
| Professional | | $2,010.50 | $2,116.32 | $2,116.32 |