- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,319.37 / $3,340.78 / $4,463.42
| Facility | | $3,319.37 | $3,340.78 | $4,463.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,859.41 / $3,664.00 / $5,099.39
| Professional | | $2,859.41 | $3,664.00 | $5,099.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,227.51 / $7,424.79 / $13,303.62
| Facility | | $6,227.51 | $7,424.79 | $13,303.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,740.27 / $3,804.46 / $5,662.55
| Professional | | $3,740.27 | $3,804.46 | $5,662.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,366.38 / $4,366.38 / $4,366.38
| Facility | | $4,366.38 | $4,366.38 | $4,366.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,187.46 / $4,366.38 / $4,510.25
| Professional | | $3,187.46 | $4,366.38 | $4,510.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,602.05 / $3,367.41 / $4,982.01
| Professional | | $2,602.05 | $3,367.41 | $4,982.01 |