- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,691.53 / $2,691.53 / $21,877.62
| Facility | | $2,691.53 | $2,691.53 | $21,877.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,511.89 / $2,754.23 / $2,884.03
| Professional | | $2,511.89 | $2,754.23 | $2,884.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.40 / $2,884.03 / $3,162.28
| Professional | | $2,570.40 | $2,884.03 | $3,162.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,888.44 / $6,025.60 / $13,803.84
| Facility | | $5,888.44 | $6,025.60 | $13,803.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,168.69 / $6,309.57 / $7,244.36
| Professional | | $4,168.69 | $6,309.57 | $7,244.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,365.16 / $4,365.16 / $4,365.16
| Facility | | $4,365.16 | $4,365.16 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $1,621.81 / $4,466.84
| Professional | | $1,513.56 | $1,621.81 | $4,466.84 |