- 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
- $3,019.95 / $3,388.44 / $8,912.51
| Professional | | $3,019.95 | $3,388.44 | $8,912.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $537.03 / $3,801.89 / $5,495.41
| Professional | | $537.03 | $3,801.89 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,235.94 / $4,897.79 / $9,120.11
| Professional | | $3,235.94 | $4,897.79 | $9,120.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,090.30 / $6,760.83 / $7,585.78
| Professional | | $3,090.30 | $6,760.83 | $7,585.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,073.80 / $16,218.10 / $35,481.34
| Facility | | $4,073.80 | $16,218.10 | $35,481.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,630.27 / $4,365.16 / $9,120.11
| Professional | | $2,630.27 | $4,365.16 | $9,120.11 |