- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,697.42 / $2,739.63 / $3,236.90
| Facility | | $2,697.42 | $2,739.63 | $3,236.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,042.58 / $2,742.31 / $3,802.86
| Professional | | $2,042.58 | $2,742.31 | $3,802.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,565.92 / $5,520.20 / $10,232.70
| Facility | | $4,565.92 | $5,520.20 | $10,232.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,776.59 / $2,776.59 / $3,941.99
| Professional | | $2,776.59 | $2,776.59 | $3,941.99 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,853.06 / $2,853.06 / $2,853.06
| Facility | | $2,853.06 | $2,853.06 | $2,853.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,082.73 / $2,853.06 / $3,510.17
| Professional | | $2,082.73 | $2,853.06 | $3,510.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,898.24 / $2,495.41 / $3,612.72
| Professional | | $1,898.24 | $2,495.41 | $3,612.72 |