- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,691.53 / $4,897.79 / $4,897.79
| Facility | | $2,691.53 | $4,897.79 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $2,398.83 / $3,630.78
| Professional | | $1,949.84 | $2,398.83 | $3,630.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $501.19 / $501.19 / $1,819.70
| Facility | | $501.19 | $501.19 | $1,819.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $588.84 / $2,951.21 / $2,951.21
| Professional | | $588.84 | $2,951.21 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $2,818.38 / $3,235.94
| Professional | | $1,778.28 | $2,818.38 | $3,235.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,691.53 / $4,897.79 / $6,309.57
| Facility | | $2,691.53 | $4,897.79 | $6,309.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $2,454.71 / $3,311.31
| Professional | | $1,949.84 | $2,454.71 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $2,691.53 / $3,311.31
| Professional | | $1,778.28 | $2,691.53 | $3,311.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $3,890.45 / $6,025.60
| Facility | | $1,698.24 | $3,890.45 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $2,754.23 / $3,715.35
| Professional | | $2,238.72 | $2,754.23 | $3,715.35 |