- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,089.30 / $4,897.79 / $4,897.79
| Facility | | $2,089.30 | $4,897.79 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $1,698.24 / $2,454.71
| Professional | | $1,445.44 | $1,698.24 | $2,454.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $457.09 / $457.09 / $3,981.07
| Facility | | $457.09 | $457.09 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,691.53 / $2,818.38 / $3,981.07
| Professional | | $2,691.53 | $2,818.38 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,238.72 / $3,311.31
| Professional | | $1,819.70 | $2,238.72 | $3,311.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,089.30 / $4,897.79 / $5,623.41
| Facility | | $2,089.30 | $4,897.79 | $5,623.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $2,089.30 / $2,818.38
| Professional | | $1,548.82 | $2,089.30 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $2,238.72 / $2,754.23
| Professional | | $1,905.46 | $2,238.72 | $2,754.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,290.87 / $6,025.60 / $10,232.93
| Facility | | $2,290.87 | $6,025.60 | $10,232.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,187.76 / $2,951.21
| Professional | | $1,819.70 | $2,187.76 | $2,951.21 |