- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,137.96 / $5,495.41 / $7,762.47
| Facility | | $2,137.96 | $5,495.41 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $2,344.23 / $2,691.53
| Professional | | $1,949.84 | $2,344.23 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,235.94 / $4,365.16 / $10,715.19
| Professional | | $3,235.94 | $4,365.16 | $10,715.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,344.23 / $2,754.23 / $6,918.31
| Professional | | $2,344.23 | $2,754.23 | $6,918.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,691.53 / $5,495.41 / $6,025.60
| Professional | | $2,691.53 | $5,495.41 | $6,025.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,311.31 / $14,791.08 / $26,915.35
| Facility | | $3,311.31 | $14,791.08 | $26,915.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,691.53 / $5,888.44
| Professional | | $2,041.74 | $2,691.53 | $5,888.44 |