- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $2,398.83 / $4,365.16
| Facility | | $2,398.83 | $2,398.83 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $2,398.83 / $4,073.80
| Professional | | $2,238.72 | $2,398.83 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,370.32 / $5,495.41 / $6,918.31
| Professional | | $5,370.32 | $5,495.41 | $6,918.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,884.03 / $3,388.44 / $6,309.57
| Facility | | $2,884.03 | $3,388.44 | $6,309.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $4,365.16 / $18,197.01
| Professional | | $2,238.72 | $4,365.16 | $18,197.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,011.87 / $5,370.32 / $5,623.41
| Professional | | $5,011.87 | $5,370.32 | $5,623.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,011.87 / $5,011.87 / $5,011.87
| Professional | | $5,011.87 | $5,011.87 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,884.03 / $4,168.69 / $4,677.35
| Professional | | $2,884.03 | $4,168.69 | $4,677.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,995.26 / $1,995.26 / $1,995.26
| Facility | | $1,995.26 | $1,995.26 | $1,995.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,630.27 / $4,570.88 / $6,760.83
| Professional | | $2,630.27 | $4,570.88 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,677.35 / $5,495.41 / $5,754.40
| Professional | | $4,677.35 | $5,495.41 | $5,754.40 |