- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,897.79 / $4,897.79 / $5,754.40
| Facility | | $4,897.79 | $4,897.79 | $5,754.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,513.56 / $2,691.53
| Professional | | $1,288.25 | $1,513.56 | $2,691.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,412.54 / $2,290.87 / $2,290.87
| Facility | | $1,412.54 | $2,290.87 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $2,290.87 / $2,398.83
| Professional | | $1,348.96 | $2,290.87 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,819.70 / $4,365.16
| Professional | | $1,148.15 | $1,819.70 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,949.84 / $4,897.79 / $6,918.31
| Facility | | $1,949.84 | $4,897.79 | $6,918.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,698.24 / $2,290.87
| Professional | | $1,380.38 | $1,698.24 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,584.89 / $2,754.23
| Professional | | $1,096.48 | $1,584.89 | $2,754.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,073.80 / $7,943.28 / $14,791.08
| Facility | | $4,073.80 | $7,943.28 | $14,791.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $1,737.80 / $2,238.72
| Professional | | $1,445.44 | $1,737.80 | $2,238.72 |