- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,966.32 / $3,061.86 / $3,595.19
| Facility | | $2,966.32 | $3,061.86 | $3,595.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,460.75 / $3,066.66 / $4,422.72
| Professional | | $2,460.75 | $3,066.66 | $4,422.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,479.34 / $6,924.85 / $11,457.48
| Facility | | $5,479.34 | $6,924.85 | $11,457.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,205.32 / $3,205.32 / $5,269.32
| Professional | | $3,205.32 | $3,205.32 | $5,269.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,072.36 / $4,072.36 / $4,072.36
| Facility | | $4,072.36 | $4,072.36 | $4,072.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,972.82 / $4,072.36 / $4,194.53
| Professional | | $2,972.82 | $4,072.36 | $4,194.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,334.37 / $2,780.70 / $4,335.22
| Professional | | $2,334.37 | $2,780.70 | $4,335.22 |