- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,798.51 / $2,798.51 / $3,358.21
| Facility | | $2,798.51 | $2,798.51 | $3,358.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,171.58 / $2,219.53 / $3,347.37
| Professional | | $2,171.58 | $2,219.53 | $3,347.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,970.12 / $4,970.12 / $5,891.58
| Facility | | $4,970.12 | $4,970.12 | $5,891.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,779.11 / $2,779.11 / $2,902.90
| Professional | | $2,779.11 | $2,779.11 | $2,902.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,294.10 / $3,294.10 / $3,294.10
| Facility | | $3,294.10 | $3,294.10 | $3,294.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,404.69 / $2,404.69 / $3,294.10
| Professional | | $2,404.69 | $2,404.69 | $3,294.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,024.08 / $4,024.08 / $12,420.32
| Professional | | $4,024.08 | $4,024.08 | $12,420.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,653.02 / $2,479.54 / $3,418.60
| Professional | | $1,653.02 | $2,479.54 | $3,418.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,722.46 / $4,094.71 / $5,211.43
| Professional | | $3,722.46 | $4,094.71 | $5,211.43 |