- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,295.94 / $2,314.54 / $2,940.10
| Facility | | $2,295.94 | $2,314.54 | $2,940.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,901.20 / $2,320.39 / $3,105.57
| Professional | | $1,901.20 | $2,320.39 | $3,105.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,130.10 / $4,640.59 / $8,425.42
| Facility | | $4,130.10 | $4,640.59 | $8,425.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,511.57 / $2,542.58 / $3,414.82
| Professional | | $2,511.57 | $2,542.58 | $3,414.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,148.57 / $3,148.57 / $3,148.57
| Facility | | $3,148.57 | $3,148.57 | $3,148.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,298.46 / $2,791.07 / $3,356.53
| Professional | | $2,298.46 | $2,791.07 | $3,356.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,717.06 / $2,199.78 / $3,267.89
| Professional | | $1,717.06 | $2,199.78 | $3,267.89 |