- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,300.15 / $2,317.54 / $2,848.38
| Facility | | $2,300.15 | $2,317.54 | $2,848.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,914.49 / $2,344.79 / $3,358.53
| Professional | | $1,914.49 | $2,344.79 | $3,358.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,466.52 / $5,112.92 / $9,331.04
| Facility | | $4,466.52 | $5,112.92 | $9,331.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,504.26 / $2,547.31 / $3,723.83
| Professional | | $2,504.26 | $2,547.31 | $3,723.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,006.81 / $3,006.81 / $3,006.81
| Facility | | $3,006.81 | $3,006.81 | $3,006.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,194.96 / $3,006.81 / $3,097.01
| Professional | | $2,194.96 | $3,006.81 | $3,097.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,733.47 / $2,281.94 / $3,343.20
| Professional | | $1,733.47 | $2,281.94 | $3,343.20 |