- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,290.87 / $3,090.30 / $4,897.79
| Facility | | $2,290.87 | $3,090.30 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,511.89 / $3,801.89
| Professional | | $2,137.96 | $2,511.89 | $3,801.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,317.64 / $19,952.62 / $27,542.29
| Facility | | $8,317.64 | $19,952.62 | $27,542.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $2,754.23 / $4,365.16
| Professional | | $1,949.84 | $2,754.23 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,949.84 / $2,187.76 / $2,290.87
| Facility | | $1,949.84 | $2,187.76 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $3,388.44 / $5,754.40
| Professional | | $2,187.76 | $3,388.44 | $5,754.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,412.54 / $5,754.40 / $12,022.64
| Facility | | $1,412.54 | $5,754.40 | $12,022.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,754.23 / $4,466.84
| Professional | | $2,041.74 | $2,754.23 | $4,466.84 |