- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,674.60 / $2,851.99 / $4,449.10
| Facility | | $2,674.60 | $2,851.99 | $4,449.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.84 / $2,500.00 / $2,500.00
| Professional | | $2,398.84 | $2,500.00 | $2,500.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,247.06 / $4,527.75 / $7,952.24
| Facility | | $3,247.06 | $4,527.75 | $7,952.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,851.99 / $3,002.09 / $3,212.24
| Professional | | $2,851.99 | $3,002.09 | $3,212.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,658.77 / $4,573.46 / $6,754.70
| Professional | | $3,658.77 | $4,573.46 | $6,754.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,851.99 / $2,851.99 / $5,240.53
| Facility | | $2,851.99 | $2,851.99 | $5,240.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,882.01 / $2,882.01 / $3,890.71
| Professional | | $2,882.01 | $2,882.01 | $3,890.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,260.88 / $1,801.25 / $3,002.09
| Professional | | $1,260.88 | $1,801.25 | $3,002.09 |