- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,073.80 / $4,073.80 / $4,897.79
| Facility | | $4,073.80 | $4,073.80 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,380.38 / $2,238.72
| Professional | | $1,174.90 | $1,380.38 | $2,238.72 |
- 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
- $1,862.09 / $2,951.21 / $3,162.28
| Professional | | $1,862.09 | $2,951.21 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,698.24 / $3,715.35
| Professional | | $1,230.27 | $1,698.24 | $3,715.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,318.26 / $4,073.80 / $4,897.79
| Facility | | $1,318.26 | $4,073.80 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,445.44 / $1,905.46
| Professional | | $1,202.26 | $1,445.44 | $1,905.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,513.56 / $2,884.03
| Professional | | $1,071.52 | $1,513.56 | $2,884.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,071.52 / $7,943.28 / $18,197.01
| Facility | | $1,071.52 | $7,943.28 | $18,197.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,548.82 / $2,187.76
| Professional | | $1,202.26 | $1,548.82 | $2,187.76 |