- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,897.79 / $4,897.79 / $5,495.41
| Facility | | $4,897.79 | $4,897.79 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,754.23 / $4,897.79 / $6,309.57
| Professional | | $2,754.23 | $4,897.79 | $6,309.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,230.27 / $9,120.11 / $9,120.11
| Facility | | $1,230.27 | $9,120.11 | $9,120.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,801.89 / $6,165.95 / $9,120.11
| Professional | | $3,801.89 | $6,165.95 | $9,120.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $4,786.30 / $6,760.83
| Professional | | $2,238.72 | $4,786.30 | $6,760.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,897.79 / $5,495.41 / $13,182.57
| Facility | | $4,897.79 | $5,495.41 | $13,182.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,890.45 / $5,128.61 / $6,918.31
| Professional | | $3,890.45 | $5,128.61 | $6,918.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.74 / $3,715.35 / $6,456.54
| Professional | | $2,041.74 | $3,715.35 | $6,456.54 |
- 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
- $2,041.74 / $5,128.61 / $7,079.46
| Professional | | $2,041.74 | $5,128.61 | $7,079.46 |