- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,580.61 / $2,616.46 / $3,211.02
| Facility | | $2,580.61 | $2,616.46 | $3,211.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,048.69 / $2,652.17 / $3,758.92
| Professional | | $2,048.69 | $2,652.17 | $3,758.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,778.05 / $5,894.38 / $9,752.52
| Facility | | $4,778.05 | $5,894.38 | $9,752.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,708.77 / $2,731.85 / $4,272.66
| Professional | | $2,708.77 | $2,731.85 | $4,272.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,813.78 / $3,813.78 / $3,813.78
| Facility | | $3,813.78 | $3,813.78 | $3,813.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,784.06 / $3,391.89 / $3,928.19
| Professional | | $2,784.06 | $3,391.89 | $3,928.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,981.78 / $2,531.09 / $3,588.30
| Professional | | $1,981.78 | $2,531.09 | $3,588.30 |