- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,414.32 / $2,574.44 / $4,016.14
| Facility | | $2,414.32 | $2,574.44 | $4,016.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,167.96 / $2,317.00 / $4,505.29
| Professional | | $2,167.96 | $2,317.00 | $4,505.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,900.35 / $1,900.35 / $1,900.35
| Facility | | $1,900.35 | $1,900.35 | $1,900.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,805.33 / $1,900.35 / $2,113.76
| Professional | | $1,805.33 | $1,900.35 | $2,113.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,302.76 / $3,302.76 / $4,128.45
| Professional | | $3,302.76 | $3,302.76 | $4,128.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,574.44 / $2,574.44 / $4,730.55
| Facility | | $2,574.44 | $2,574.44 | $4,730.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,601.55 / $2,601.55 / $3,411.41
| Professional | | $2,601.55 | $2,601.55 | $3,411.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,138.18 / $1,625.97 / $2,709.95
| Professional | | $1,138.18 | $1,625.97 | $2,709.95 |