- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,238.72 / $4,897.79 / $4,897.79
| Facility | | $2,238.72 | $4,897.79 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $1,778.28 / $3,162.28
| Professional | | $1,479.11 | $1,778.28 | $3,162.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,630.27 / $2,630.27 / $2,630.27
| Facility | | $2,630.27 | $2,630.27 | $2,630.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $524.81 / $2,630.27 / $2,630.27
| Professional | | $524.81 | $2,630.27 | $2,630.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $2,041.74 / $4,570.88
| Professional | | $1,412.54 | $2,041.74 | $4,570.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,238.72 / $4,897.79 / $5,495.41
| Facility | | $2,238.72 | $4,897.79 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $2,041.74 / $2,884.03
| Professional | | $1,659.59 | $2,041.74 | $2,884.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,737.80 / $3,162.28
| Professional | | $1,318.26 | $1,737.80 | $3,162.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,230.27 / $3,890.45 / $6,025.60
| Facility | | $1,230.27 | $3,890.45 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $1,949.84 / $2,454.71
| Professional | | $1,621.81 | $1,949.84 | $2,454.71 |