- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,466.84 / $5,495.41 / $5,495.41
| Facility | | $4,466.84 | $5,495.41 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $1,862.09 / $2,754.23
| Professional | | $1,659.59 | $1,862.09 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $1,778.28 / $1,778.28
| Professional | | $1,479.11 | $1,778.28 | $1,778.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,659.59 / $2,041.74 / $5,495.41
| Facility | | $1,659.59 | $2,041.74 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $1,862.09 / $2,754.23
| Professional | | $1,659.59 | $1,862.09 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.20 / $30.20 / $30.20
| Professional | | $30.20 | $30.20 | $30.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,691.53 / $2,818.38 / $2,951.21
| Professional | | $2,691.53 | $2,818.38 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $1,778.28 / $1,949.84
| Professional | | $1,778.28 | $1,778.28 | $1,949.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $15,488.17 / $26,302.68
| Facility | | $3,715.35 | $15,488.17 | $26,302.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $2,630.27 / $3,981.07
| Professional | | $1,949.84 | $2,630.27 | $3,981.07 |