- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,717.01 / $2,948.92 / $3,205.54
| Facility | | $2,717.01 | $2,948.92 | $3,205.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,247.82 / $2,968.95 / $3,484.42
| Professional | | $2,247.82 | $2,968.95 | $3,484.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,660.81 / $3,752.33 / $6,051.96
| Facility | | $3,660.81 | $3,752.33 | $6,051.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,868.89 / $1,868.90 / $2,720.68
| Professional | | $1,868.89 | $1,868.90 | $2,720.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,290.01 / $4,290.01 / $4,290.01
| Facility | | $4,290.01 | $4,290.01 | $4,290.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,700.00 / $1,700.00 / $1,700.00
| Professional | | $1,700.00 | $1,700.00 | $1,700.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,712.23 / $2,893.88 / $4,751.62
| Professional | | $1,712.23 | $2,893.88 | $4,751.62 |