- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,581.48 / $2,676.93 / $3,603.33
| Facility | | $2,581.48 | $2,676.93 | $3,603.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,467.91 / $2,684.09 / $4,398.42
| Professional | | $2,467.91 | $2,684.09 | $4,398.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,075.70 / $5,776.35 / $9,557.24
| Facility | | $5,075.70 | $5,776.35 | $9,557.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,246.42 / $3,443.26 / $4,988.82
| Professional | | $3,246.42 | $3,443.26 | $4,988.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,323.97 / $3,323.97 / $3,323.97
| Facility | | $3,323.97 | $3,323.97 | $3,323.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,426.50 / $3,323.97 / $3,423.69
| Professional | | $2,426.50 | $3,323.97 | $3,423.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,136.31 / $2,818.90 / $4,222.00
| Professional | | $2,136.31 | $2,818.90 | $4,222.00 |