- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,352.08 / $2,352.08 / $2,822.50
| Facility | | $2,352.08 | $2,352.08 | $2,822.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,653.87 / $1,825.16 / $2,811.74
| Professional | | $1,653.87 | $1,825.16 | $2,811.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,177.29 / $4,177.29 / $4,951.76
| Facility | | $4,177.29 | $4,177.29 | $4,951.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,262.55 / $2,262.55 / $2,363.34
| Professional | | $2,262.55 | $2,262.55 | $2,363.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,970.85 / $2,970.85 / $2,970.85
| Facility | | $2,970.85 | $2,970.85 | $2,970.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,168.71 / $2,168.71 / $3,070.25
| Professional | | $2,168.71 | $2,168.71 | $3,070.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,382.15 / $3,382.15 / $10,439.01
| Professional | | $3,382.15 | $3,382.15 | $10,439.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,389.33 / $2,084.00 / $3,328.35
| Professional | | $1,389.33 | $2,084.00 | $3,328.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,128.65 / $3,441.52 / $4,380.10
| Professional | | $3,128.65 | $3,441.52 | $4,380.10 |