- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,951.21 / $2,951.21 / $21,877.62
| Facility | | $2,951.21 | $2,951.21 | $21,877.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,754.23 / $2,951.21 / $3,162.28
| Professional | | $2,754.23 | $2,951.21 | $3,162.28 |
- 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
- $6,309.57 / $6,606.93 / $13,803.84
| Facility | | $6,309.57 | $6,606.93 | $13,803.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,168.69 / $4,168.69 / $7,244.36
| Professional | | $4,168.69 | $4,168.69 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $1,778.28 / $4,897.79
| Professional | | $1,659.59 | $1,778.28 | $4,897.79 |