- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,570.62 / $2,700.19 / $3,334.09
| Facility | | $2,570.62 | $2,700.19 | $3,334.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,104.96 / $2,736.94 / $3,853.72
| Professional | | $2,104.96 | $2,736.94 | $3,853.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,584.43 / $5,776.69 / $10,326.26
| Facility | | $4,584.43 | $5,776.69 | $10,326.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,787.85 / $2,800.76 / $4,229.82
| Professional | | $2,787.85 | $2,800.76 | $4,229.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,670.30 / $3,670.30 / $3,670.30
| Facility | | $3,670.30 | $3,670.30 | $3,670.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,679.32 / $3,627.73 / $3,780.41
| Professional | | $2,679.32 | $3,627.73 | $3,780.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,991.07 / $2,522.41 / $3,866.55
| Professional | | $1,991.07 | $2,522.41 | $3,866.55 |