- 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
- $2,951.21 / $3,890.45 / $10,232.93
| Professional | | $2,951.21 | $3,890.45 | $10,232.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,890.45 / $6,918.31 / $15,135.61
| Professional | | $3,890.45 | $6,918.31 | $15,135.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,715.35 / $5,754.40 / $10,715.19
| Professional | | $3,715.35 | $5,754.40 | $10,715.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,630.78 / $7,762.47 / $8,709.64
| Professional | | $3,630.78 | $7,762.47 | $8,709.64 |
- 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
- $2,884.03 / $5,011.87 / $10,471.29
| Professional | | $2,884.03 | $5,011.87 | $10,471.29 |