- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,044.52 / $2,075.80 / $2,381.48
| Facility | | $2,044.52 | $2,075.80 | $2,381.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,777.44 / $2,044.52 / $2,957.24
| Professional | | $1,777.44 | $2,044.52 | $2,957.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,805.64 / $4,289.87 / $7,788.66
| Facility | | $3,805.64 | $4,289.87 | $7,788.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,186.20 / $2,199.78 / $3,143.29
| Professional | | $2,186.20 | $2,199.78 | $3,143.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,214.74 / $3,214.74 / $3,214.74
| Facility | | $3,214.74 | $3,214.74 | $3,214.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,732.53 / $2,732.53 / $3,311.18
| Professional | | $2,732.53 | $2,732.53 | $3,311.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,522.93 / $2,021.93 / $2,874.20
| Professional | | $1,522.93 | $2,021.93 | $2,874.20 |