- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,073.80 / $4,073.80 / $5,888.44
| Facility | | $4,073.80 | $4,073.80 | $5,888.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,513.56 / $2,187.76
| Professional | | $1,230.27 | $1,513.56 | $2,187.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,290.87 / $4,265.80 / $8,128.31
| Facility | | $2,290.87 | $4,265.80 | $8,128.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $2,344.23 / $2,344.23
| Professional | | $2,290.87 | $2,344.23 | $2,344.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,778.28 / $4,786.30 / $8,912.51
| Facility | | $1,778.28 | $4,786.30 | $8,912.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,621.81 / $2,951.21 / $4,466.84
| Facility | | $1,621.81 | $2,951.21 | $4,466.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,754.23 / $2,818.38
| Professional | | $2,187.76 | $2,754.23 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.20 / $30.20 / $30.20
| Professional | | $30.20 | $30.20 | $30.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,388.44 / $4,466.84 / $8,128.31
| Facility | | $3,388.44 | $4,466.84 | $8,128.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $1,949.84 / $2,398.83
| Professional | | $1,949.84 | $1,949.84 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $2,290.87 / $2,290.87
| Professional | | $2,290.87 | $2,290.87 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $954.99 / $954.99 / $2,290.87
| Professional | | $954.99 | $954.99 | $2,290.87 |