- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,269.29 / $5,269.29 / $7,590.96
| Facility | | $5,269.29 | $5,269.29 | $7,590.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,043.72 / $5,693.22 / $5,693.22
| Professional | | $2,043.72 | $5,693.22 | $5,693.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,846.61 / $3,093.32 / $11,386.44
| Facility | | $2,846.61 | $3,093.32 | $11,386.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,176.35 / $3,354.80 / $4,831.79
| Professional | | $2,176.35 | $3,354.80 | $4,831.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,744.42 / $5,693.22 / $6,262.54
| Facility | | $2,744.42 | $5,693.22 | $6,262.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,919.60 / $2,919.60 / $3,503.52
| Professional | | $2,919.60 | $2,919.60 | $3,503.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,233.48 / $2,627.64 / $5,693.22
| Professional | | $2,233.48 | $2,627.64 | $5,693.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,379.39 / $5,839.20 / $10,510.56
| Facility | | $4,379.39 | $5,839.20 | $10,510.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,481.66 / $5,135.42 / $5,135.42
| Professional | | $2,481.66 | $5,135.42 | $5,135.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,226.23 / $1,226.23 / $3,503.52
| Professional | | $1,226.23 | $1,226.23 | $3,503.52 |