- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,243.49 / $3,274.56 / $3,715.22
| Facility | | $3,243.49 | $3,274.56 | $3,715.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,759.41 / $3,274.56 / $4,786.46
| Professional | | $2,759.41 | $3,274.56 | $4,786.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,183.15 / $6,683.81 / $12,366.30
| Facility | | $6,183.15 | $6,683.81 | $12,366.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,259.28 / $3,438.30 / $6,369.31
| Professional | | $3,259.28 | $3,438.30 | $6,369.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,799.01 / $3,799.01 / $3,799.01
| Facility | | $3,799.01 | $3,799.01 | $3,799.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,229.16 / $3,229.16 / $3,912.98
| Professional | | $3,229.16 | $3,229.16 | $3,912.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,423.52 / $3,177.58 / $4,443.81
| Professional | | $2,423.52 | $3,177.58 | $4,443.81 |