- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,084.37 / $3,126.45 / $4,181.96
| Facility | | $3,084.37 | $3,126.45 | $4,181.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,704.26 / $3,287.43 / $4,972.55
| Professional | | $2,704.26 | $3,287.43 | $4,972.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,582.09 / $6,948.46 / $11,496.54
| Facility | | $5,582.09 | $6,948.46 | $11,496.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,562.16 / $3,643.96 / $5,213.12
| Professional | | $3,562.16 | $3,643.96 | $5,213.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,052.23 / $4,052.23 / $4,052.23
| Facility | | $4,052.23 | $4,052.23 | $4,052.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,958.13 / $3,998.46 / $4,173.80
| Professional | | $2,958.13 | $3,998.46 | $4,173.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,337.30 / $3,134.89 / $4,521.06
| Professional | | $2,337.30 | $3,134.89 | $4,521.06 |