- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,282.67 / $2,425.17 / $2,910.22
| Facility | | $2,282.67 | $2,425.17 | $2,910.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,941.31 / $2,425.17 / $3,517.44
| Professional | | $1,941.31 | $2,425.17 | $3,517.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,027.56 / $4,729.35 / $8,456.40
| Facility | | $4,027.56 | $4,729.35 | $8,456.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,739.20 / $3,043.56 / $4,019.15
| Professional | | $2,739.20 | $3,043.56 | $4,019.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,001.57 / $3,001.57 / $3,001.57
| Facility | | $3,001.57 | $3,001.57 | $3,001.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,191.15 / $3,001.57 / $3,199.83
| Professional | | $2,191.15 | $3,001.57 | $3,199.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,694.86 / $2,349.37 / $3,291.83
| Professional | | $1,694.86 | $2,349.37 | $3,291.83 |