- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,495.41 / $9,120.11 / $9,120.11
| Facility | | $5,495.41 | $9,120.11 | $9,120.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,659.59 / $1,862.09
| Professional | | $1,202.26 | $1,659.59 | $1,862.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $1,737.80 / $1,737.80
| Professional | | $1,737.80 | $1,737.80 | $1,737.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,548.13 / $3,715.35 / $3,715.35
| Facility | | $3,548.13 | $3,715.35 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10,715.19 / $10,715.19 / $10,715.19
| Professional | | $10,715.19 | $10,715.19 | $10,715.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,344.23 / $3,019.95 / $4,786.30
| Professional | | $2,344.23 | $3,019.95 | $4,786.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.83 / $3,715.35 / $5,623.41
| Professional | | $2,398.83 | $3,715.35 | $5,623.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,495.41 / $9,120.11 / $9,120.11
| Facility | | $5,495.41 | $9,120.11 | $9,120.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,778.28 / $2,570.40
| Professional | | $1,202.26 | $1,778.28 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $2,238.72 / $2,454.71
| Professional | | $2,238.72 | $2,238.72 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,318.26 / $2,754.23
| Professional | | $933.25 | $1,318.26 | $2,754.23 |