- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,412.21 / $3,412.21 / $3,485.39
| Facility | | $3,412.21 | $3,412.21 | $3,485.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,603.19 / $3,353.48 / $4,371.41
| Professional | | $2,603.19 | $3,353.48 | $4,371.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,372.22 / $2,372.22 / $2,372.22
| Facility | | $2,372.22 | $2,372.22 | $2,372.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,695.35 / $2,959.91 / $4,045.18
| Professional | | $2,695.35 | $2,959.91 | $4,045.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,673.00 / $2,673.00 / $3,172.80
| Facility | | $2,673.00 | $2,673.00 | $3,172.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $421.95 / $2,673.00 / $4,219.47
| Professional | | $421.95 | $2,673.00 | $4,219.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,533.15 / $2,093.23 / $3,540.27
| Professional | | $1,533.15 | $2,093.23 | $3,540.27 |