- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,593.44 / $2,647.12 / $3,353.03
| Facility | | $2,593.44 | $2,647.12 | $3,353.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,099.46 / $2,780.95 / $3,951.93
| Professional | | $2,099.46 | $2,780.95 | $3,951.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,701.26 / $6,168.54 / $10,685.75
| Facility | | $4,701.26 | $6,168.54 | $10,685.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,872.13 / $2,872.13 / $4,579.66
| Professional | | $2,872.13 | $2,872.13 | $4,579.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,798.08 / $3,798.08 / $3,798.08
| Facility | | $3,798.08 | $3,798.08 | $3,798.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,772.60 / $3,716.46 / $4,048.94
| Professional | | $2,772.60 | $3,716.46 | $4,048.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,018.87 / $2,473.12 / $3,782.25
| Professional | | $2,018.87 | $2,473.12 | $3,782.25 |