- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,884.03 / $2,884.03 / $23,442.29
| Facility | | $2,884.03 | $2,884.03 | $23,442.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,691.53 / $2,951.21 / $3,162.28
| Professional | | $2,691.53 | $2,951.21 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,818.38 / $3,090.30 / $3,388.44
| Professional | | $2,818.38 | $3,090.30 | $3,388.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,309.57 / $6,606.93 / $14,791.08
| Facility | | $6,309.57 | $6,606.93 | $14,791.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,466.84 / $6,760.83 / $7,943.28
| Professional | | $4,466.84 | $6,760.83 | $7,943.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,677.35 / $4,677.35 / $4,677.35
| Facility | | $4,677.35 | $4,677.35 | $4,677.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $1,737.80 / $4,786.30
| Professional | | $1,621.81 | $1,737.80 | $4,786.30 |