- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,137.96 / $5,128.61 / $7,762.47
| Facility | | $2,137.96 | $5,128.61 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $2,630.27 / $7,762.47
| Professional | | $2,238.72 | $2,630.27 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,818.38 / $3,890.45 / $10,715.19
| Professional | | $2,818.38 | $3,890.45 | $10,715.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,511.89 / $4,168.69 / $7,079.46
| Professional | | $2,511.89 | $4,168.69 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $5,248.07 / $5,888.44
| Professional | | $2,290.87 | $5,248.07 | $5,888.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,073.80 / $16,218.10 / $33,884.42
| Facility | | $4,073.80 | $16,218.10 | $33,884.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,344.23 / $3,388.44 / $7,079.46
| Professional | | $2,344.23 | $3,388.44 | $7,079.46 |