- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,592.48 / $2,625.09 / $3,110.97
| Facility | | $2,592.48 | $2,625.09 | $3,110.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,006.86 / $2,625.09 / $3,461.55
| Professional | | $2,006.86 | $2,625.09 | $3,461.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,489.85 / $5,530.30 / $9,828.00
| Facility | | $4,489.85 | $5,530.30 | $9,828.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,670.21 / $2,670.21 / $4,151.88
| Professional | | $2,670.21 | $2,670.21 | $4,151.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,523.90 / $3,523.90 / $3,523.90
| Facility | | $3,523.90 | $3,523.90 | $3,523.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,572.44 / $3,448.16 / $3,629.62
| Professional | | $2,572.44 | $3,448.16 | $3,629.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,839.34 / $2,626.71 / $3,602.54
| Professional | | $1,839.34 | $2,626.71 | $3,602.54 |