- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $912.01 / $1,548.82 / $2,398.83
| Facility | | $912.01 | $1,548.82 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $1,047.13 / $2,187.76
| Professional | | $870.96 | $1,047.13 | $2,187.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,265.80 / $8,709.64 / $11,220.18
| Facility | | $4,265.80 | $8,709.64 | $11,220.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $1,000.00 / $1,548.82
| Professional | | $741.31 | $1,000.00 | $1,548.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $954.99 / $977.24 / $1,122.02
| Facility | | $954.99 | $977.24 | $1,122.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $912.01 / $1,174.90 / $2,041.74
| Facility | | $912.01 | $1,174.90 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $1,122.02 / $2,041.74
| Professional | | $794.33 | $1,122.02 | $2,041.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,128.61 / $11,481.54 / $17,378.01
| Facility | | $5,128.61 | $11,481.54 | $17,378.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $1,071.52 / $1,737.80
| Professional | | $794.33 | $1,071.52 | $1,737.80 |