- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,187.76 / $17,782.79
| Facility | | $2,187.76 | $2,187.76 | $17,782.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,238.72 / $2,344.23
| Professional | | $2,041.74 | $2,238.72 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,344.23 / $2,570.40
| Professional | | $2,089.30 | $2,344.23 | $2,570.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,786.30 / $4,897.79 / $11,220.18
| Facility | | $4,786.30 | $4,897.79 | $11,220.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,388.44 / $3,388.44 / $5,888.44
| Professional | | $3,388.44 | $3,388.44 | $5,888.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,467.37 / $3,467.37 / $3,467.37
| Facility | | $3,467.37 | $3,467.37 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,318.26 / $3,630.78
| Professional | | $1,230.27 | $1,318.26 | $3,630.78 |