- 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
- $1,202.26 / $1,479.11 / $2,187.76
| Professional | | $1,202.26 | $1,479.11 | $2,187.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,862.09 / $1,862.09 / $2,818.38
| Facility | | $1,862.09 | $1,862.09 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $371.54 / $2,630.27 / $2,818.38
| Professional | | $371.54 | $2,630.27 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,659.59 / $2,089.30
| Professional | | $1,122.02 | $1,659.59 | $2,089.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,659.59 / $4,897.79 / $6,918.31
| Facility | | $1,659.59 | $4,897.79 | $6,918.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,479.11 / $1,995.26
| Professional | | $1,202.26 | $1,479.11 | $1,995.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,412.54 / $1,949.84
| Professional | | $1,122.02 | $1,412.54 | $1,949.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,454.71 / $5,754.40 / $9,120.11
| Facility | | $2,454.71 | $5,754.40 | $9,120.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,659.59 / $2,238.72
| Professional | | $1,348.96 | $1,659.59 | $2,238.72 |