- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,565.06 / $2,565.06 / $2,715.89
| Facility | | $2,565.06 | $2,565.06 | $2,715.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,039.74 / $2,479.73 / $3,214.07
| Professional | | $2,039.74 | $2,479.73 | $3,214.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,964.43 / $4,079.47 / $5,234.68
| Facility | | $3,964.43 | $4,079.47 | $5,234.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,257.26 / $3,129.41 / $3,304.37
| Professional | | $2,257.26 | $3,129.41 | $3,304.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,672.64 / $2,672.64 / $2,672.64
| Facility | | $2,672.64 | $2,672.64 | $2,672.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,271.73 / $2,672.64 / $4,576.38
| Professional | | $2,271.73 | $2,672.64 | $4,576.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,553.41 / $2,047.28 / $3,412.13
| Professional | | $1,553.41 | $2,047.28 | $3,412.13 |