- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,454.71 / $2,454.71 / $19,952.62
| Facility | | $2,454.71 | $2,454.71 | $19,952.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $2,454.71 / $2,630.27
| Professional | | $2,290.87 | $2,454.71 | $2,630.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,344.23 / $2,570.40 / $2,818.38
| Professional | | $2,344.23 | $2,570.40 | $2,818.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,248.07 / $5,495.41 / $12,302.69
| Facility | | $5,248.07 | $5,495.41 | $12,302.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,715.35 / $3,715.35 / $6,606.93
| Professional | | $3,715.35 | $3,715.35 | $6,606.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,890.45 / $3,890.45 / $3,890.45
| Facility | | $3,890.45 | $3,890.45 | $3,890.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,445.44 / $4,073.80
| Professional | | $1,348.96 | $1,445.44 | $4,073.80 |