- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,041.74 / $4,897.79
| Facility | | $2,041.74 | $2,041.74 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,318.26 / $2,344.23
| Professional | | $1,122.02 | $1,318.26 | $2,344.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $389.05 / $2,951.21 / $2,951.21
| Facility | | $389.05 | $2,951.21 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $2,951.21 / $2,951.21
| Professional | | $1,949.84 | $2,951.21 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $954.99 / $1,479.11 / $2,951.21
| Professional | | $954.99 | $1,479.11 | $2,951.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,659.59 / $2,884.03 / $4,897.79
| Facility | | $1,659.59 | $2,884.03 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,380.38 / $1,905.46
| Professional | | $1,096.48 | $1,380.38 | $1,905.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $954.99 / $1,412.54 / $2,398.83
| Professional | | $954.99 | $1,412.54 | $2,398.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,265.80 / $7,585.78 / $15,135.61
| Facility | | $4,265.80 | $7,585.78 | $15,135.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,479.11 / $1,905.46
| Professional | | $1,230.27 | $1,479.11 | $1,905.46 |