- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,906.89 / $2,922.45 / $3,701.40
| Facility | | $2,906.89 | $2,922.45 | $3,701.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,455.41 / $2,922.45 / $4,309.50
| Professional | | $2,455.41 | $2,922.45 | $4,309.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,460.46 / $6,157.35 / $10,487.50
| Facility | | $5,460.46 | $6,157.35 | $10,487.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,159.00 / $3,569.66 / $4,816.77
| Professional | | $3,159.00 | $3,569.66 | $4,816.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,728.42 / $3,728.42 / $3,728.42
| Facility | | $3,728.42 | $3,728.42 | $3,728.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,721.75 / $3,728.42 / $3,840.27
| Professional | | $2,721.75 | $3,728.42 | $3,840.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,135.42 / $2,874.78 / $4,270.84
| Professional | | $2,135.42 | $2,874.78 | $4,270.84 |