- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,490.62 / $2,537.62 / $3,256.00
| Facility | | $2,490.62 | $2,537.62 | $3,256.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,105.48 / $2,649.64 / $3,638.71
| Professional | | $2,105.48 | $2,649.64 | $3,638.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,818.83 / $5,158.58 / $9,637.66
| Facility | | $4,818.83 | $5,158.58 | $9,637.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,646.44 / $2,828.47 / $3,937.02
| Professional | | $2,646.44 | $2,828.47 | $3,937.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,756.64 / $2,756.64 / $2,756.64
| Facility | | $2,756.64 | $2,756.64 | $2,756.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,012.35 / $2,012.35 / $5,300.71
| Professional | | $2,012.35 | $2,012.35 | $5,300.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,776.96 / $2,404.07 / $3,621.39
| Professional | | $1,776.96 | $2,404.07 | $3,621.39 |