- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,674.76 / $2,700.78 / $3,158.81
| Facility | | $2,674.76 | $2,700.78 | $3,158.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,280.28 / $2,703.23 / $3,793.86
| Professional | | $2,280.28 | $2,703.23 | $3,793.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,071.58 / $5,935.66 / $10,066.78
| Facility | | $5,071.58 | $5,935.66 | $10,066.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,902.58 / $2,952.48 / $4,456.21
| Professional | | $2,902.58 | $2,952.48 | $4,456.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,578.08 / $3,578.08 / $3,578.08
| Facility | | $3,578.08 | $3,578.08 | $3,578.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,612.00 / $2,612.00 / $5,673.94
| Professional | | $2,612.00 | $2,612.00 | $5,673.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,155.94 / $2,627.87 / $3,958.79
| Professional | | $2,155.94 | $2,627.87 | $3,958.79 |