- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,289.87 / $2,324.90 / $2,667.28
| Facility | | $2,289.87 | $2,324.90 | $2,667.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,990.74 / $2,289.87 / $3,312.12
| Professional | | $1,990.74 | $2,289.87 | $3,312.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,276.13 / $4,804.66 / $8,723.31
| Facility | | $4,276.13 | $4,804.66 | $8,723.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,433.34 / $2,478.96 / $3,591.18
| Professional | | $2,433.34 | $2,478.96 | $3,591.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,600.52 / $3,600.52 / $3,600.52
| Facility | | $3,600.52 | $3,600.52 | $3,600.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,060.44 / $3,060.44 / $3,708.54
| Professional | | $3,060.44 | $3,060.44 | $3,708.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,684.38 / $2,264.57 / $3,205.69
| Professional | | $1,684.38 | $2,264.57 | $3,205.69 |