- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,354.21 / $3,588.75 / $4,306.50
| Facility | | $2,354.21 | $3,588.75 | $4,306.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,153.25 / $2,354.21 / $2,440.35
| Professional | | $2,153.25 | $2,354.21 | $2,440.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,158.10 / $4,306.50 / $5,024.25
| Facility | | $3,158.10 | $4,306.50 | $5,024.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,445.20 / $3,445.20 / $3,875.85
| Professional | | $3,445.20 | $3,445.20 | $3,875.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,332.69 / $3,445.20 / $8,612.28
| Facility | | $2,332.69 | $3,445.20 | $8,612.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13,838.22 / $13,838.22 / $13,838.22
| Professional | | $13,838.22 | $13,838.22 | $13,838.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $893.25 / $1,291.95 / $3,158.10
| Professional | | $893.25 | $1,291.95 | $3,158.10 |