- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,347.01 / $2,493.89 / $3,454.25
| Facility | | $2,347.01 | $2,493.89 | $3,454.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,060.84 / $2,549.32 / $3,684.25
| Professional | | $2,060.84 | $2,549.32 | $3,684.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,518.00 / $5,224.10 / $9,643.37
| Facility | | $4,518.00 | $5,224.10 | $9,643.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,672.78 / $2,704.43 / $3,965.38
| Professional | | $2,672.78 | $2,704.43 | $3,965.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,780.72 / $2,780.72 / $2,780.72
| Facility | | $2,780.72 | $2,780.72 | $2,780.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,029.93 / $2,780.72 / $3,394.00
| Professional | | $2,029.93 | $2,780.72 | $3,394.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,885.67 / $2,296.50 / $3,521.11
| Professional | | $1,885.67 | $2,296.50 | $3,521.11 |