- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,290.87 / $2,951.21
| Facility | | $2,187.76 | $2,290.87 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,621.81 / $3,715.35
| Professional | | $1,148.15 | $1,621.81 | $3,715.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $4,168.69 / $12,022.64
| Facility | | $3,715.35 | $4,168.69 | $12,022.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $2,691.53 / $4,073.80
| Professional | | $1,412.54 | $2,691.53 | $4,073.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $851.14 / $851.14 / $2,041.74
| Facility | | $851.14 | $851.14 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $2,691.53 / $4,168.69
| Professional | | $1,659.59 | $2,691.53 | $4,168.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $2,570.40 / $3,235.94
| Professional | | $1,659.59 | $2,570.40 | $3,235.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,677.35 / $10,232.93 / $16,218.10
| Facility | | $4,677.35 | $10,232.93 | $16,218.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $2,187.76 / $4,073.80
| Professional | | $1,230.27 | $2,187.76 | $4,073.80 |