- 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
- $1,949.84 / $2,290.87 / $4,073.80
| Professional | | $1,949.84 | $2,290.87 | $4,073.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $602.56 / $602.56 / $2,187.76
| Facility | | $602.56 | $602.56 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,511.89 / $3,548.13
| Professional | | $2,187.76 | $2,511.89 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $2,398.83 / $4,570.88
| Professional | | $1,778.28 | $2,398.83 | $4,570.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,019.95 / $5,754.40 / $6,918.31
| Facility | | $3,019.95 | $5,754.40 | $6,918.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,511.89 / $3,388.44
| Professional | | $2,137.96 | $2,511.89 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $2,290.87 / $4,365.16
| Professional | | $1,659.59 | $2,290.87 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,079.46 / $11,481.54 / $39,810.72
| Facility | | $7,079.46 | $11,481.54 | $39,810.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,511.89 / $3,311.31
| Professional | | $2,137.96 | $2,511.89 | $3,311.31 |