- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,137.96 / $6,918.31 / $8,128.31
| Facility | | $2,137.96 | $6,918.31 | $8,128.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $2,398.83 / $5,888.44
| Professional | | $1,862.09 | $2,398.83 | $5,888.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $13,489.63 / $31,622.78
| Professional | | $2,290.87 | $13,489.63 | $31,622.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $2,630.27 / $6,309.57
| Professional | | $2,290.87 | $2,630.27 | $6,309.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,344.23 / $4,073.80 / $5,248.07
| Professional | | $2,344.23 | $4,073.80 | $5,248.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,897.79 / $13,489.63 / $41,686.94
| Facility | | $4,897.79 | $13,489.63 | $41,686.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $2,754.23 / $6,309.57
| Professional | | $1,737.80 | $2,754.23 | $6,309.57 |