- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,137.96 / $3,715.35 / $7,762.47
| Facility | | $2,137.96 | $3,715.35 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,630.27 / $5,623.41
| Professional | | $2,041.74 | $2,630.27 | $5,623.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $3,467.37 / $4,570.88
| Professional | | $1,819.70 | $3,467.37 | $4,570.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.36 / $33.11 / $3,467.37
| Professional | | $32.36 | $33.11 | $3,467.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $3,311.31 / $5,370.32
| Facility | | $2,398.83 | $3,311.31 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $3,311.31 / $4,570.88
| Professional | | $1,819.70 | $3,311.31 | $4,570.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,090.30 / $5,128.61 / $19,498.45
| Facility | | $3,090.30 | $5,128.61 | $19,498.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,511.89 / $3,311.31 / $5,370.32
| Professional | | $2,511.89 | $3,311.31 | $5,370.32 |