- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,189.69 / $2,475.82 / $7,970.51
| Facility | | $2,189.69 | $2,475.82 | $7,970.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,189.69 / $2,277.29 / $2,598.44
| Professional | | $2,189.69 | $2,277.29 | $2,598.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,518.19 / $4,087.44 / $5,751.61
| Professional | | $1,518.19 | $4,087.44 | $5,751.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,926.21 / $3,503.52 / $12,977.14
| Facility | | $1,926.21 | $3,503.52 | $12,977.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,919.60 / $2,919.60 / $14,072.47
| Professional | | $2,919.60 | $2,919.60 | $14,072.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,080.10 / $13,868.10 / $13,868.10
| Facility | | $5,080.10 | $13,868.10 | $13,868.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14,539.61 / $14,539.61 / $21,897.00
| Professional | | $14,539.61 | $14,539.61 | $21,897.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,226.23 / $1,751.76 / $2,919.60
| Professional | | $1,226.23 | $1,751.76 | $2,919.60 |