- 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
- $1,096.48 / $1,380.38 / $2,290.87
| Professional | | $1,096.48 | $1,380.38 | $2,290.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $371.54 / $1,862.09 / $1,862.09
| Facility | | $371.54 | $1,862.09 | $1,862.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,862.09 / $1,949.84
| Professional | | $1,174.90 | $1,862.09 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,380.38 / $2,041.74
| Professional | | $1,096.48 | $1,380.38 | $2,041.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,479.11 / $4,897.79 / $6,918.31
| Facility | | $1,479.11 | $4,897.79 | $6,918.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,479.11 / $2,238.72
| Professional | | $1,122.02 | $1,479.11 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,380.38 / $1,995.26
| Professional | | $1,288.25 | $1,380.38 | $1,995.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,890.45 / $7,413.10 / $12,882.50
| Facility | | $3,890.45 | $7,413.10 | $12,882.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,548.82 / $2,041.74
| Professional | | $1,258.93 | $1,548.82 | $2,041.74 |