- 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
- $1,348.96 / $1,621.81 / $4,073.80
| Professional | | $1,348.96 | $1,621.81 | $4,073.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $512.86 / $602.56 / $602.56
| Facility | | $512.86 | $602.56 | $602.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.56 / $3,019.95 / $3,235.94
| Professional | | $602.56 | $3,019.95 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,862.09 / $4,365.16
| Professional | | $1,230.27 | $1,862.09 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,137.96 / $5,495.41 / $6,918.31
| Facility | | $2,137.96 | $5,495.41 | $6,918.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $2,041.74 / $3,235.94
| Professional | | $1,479.11 | $2,041.74 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,659.59 / $2,884.03
| Professional | | $1,148.15 | $1,659.59 | $2,884.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,570.40 / $6,309.57 / $10,471.29
| Facility | | $2,570.40 | $6,309.57 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,548.82 / $2,089.30
| Professional | | $1,122.02 | $1,548.82 | $2,089.30 |