- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,436.69 / $2,441.63 / $3,065.21
| Facility | | $2,436.69 | $2,441.63 | $3,065.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,083.53 / $2,441.63 / $3,614.61
| Professional | | $2,083.53 | $2,441.63 | $3,614.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,714.47 / $5,046.87 / $9,428.95
| Facility | | $4,714.47 | $5,046.87 | $9,428.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,593.79 / $2,902.12 / $3,979.24
| Professional | | $2,593.79 | $2,902.12 | $3,979.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,886.72 / $2,886.72 / $2,886.72
| Facility | | $2,886.72 | $2,886.72 | $2,886.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,107.31 / $2,886.72 / $3,077.39
| Professional | | $2,107.31 | $2,886.72 | $3,077.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,890.35 / $5,753.36 / $5,753.36
| Facility | | $4,890.35 | $5,753.36 | $5,753.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,829.98 / $2,422.62 / $3,414.19
| Professional | | $1,829.98 | $2,422.62 | $3,414.19 |