- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,489.73 / $2,494.73 / $3,131.90
| Facility | | $2,489.73 | $2,494.73 | $3,131.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,128.86 / $2,540.54 / $3,693.23
| Professional | | $2,128.86 | $2,540.54 | $3,693.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,817.09 / $5,156.68 / $9,634.18
| Facility | | $4,817.09 | $5,156.68 | $9,634.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,740.69 / $2,965.25 / $4,065.81
| Professional | | $2,740.69 | $2,965.25 | $4,065.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,801.20 / $2,801.20 / $2,801.20
| Facility | | $2,801.20 | $2,801.20 | $2,801.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,044.88 / $2,044.88 / $5,298.80
| Professional | | $2,044.88 | $2,044.88 | $5,298.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,833.99 / $2,462.21 / $3,488.48
| Professional | | $1,833.99 | $2,462.21 | $3,488.48 |