- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $3,715.35 / $6,760.83
| Facility | | $3,715.35 | $3,715.35 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,691.53 / $3,630.78 / $4,677.35
| Professional | | $2,691.53 | $3,630.78 | $4,677.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,884.03 / $4,466.84 / $7,762.47
| Facility | | $2,884.03 | $4,466.84 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,754.23 / $2,884.03 / $2,884.03
| Professional | | $2,754.23 | $2,884.03 | $2,884.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $5,370.32 / $15,135.61
| Professional | | $2,187.76 | $5,370.32 | $15,135.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $3,715.35 / $9,332.54
| Facility | | $3,715.35 | $3,715.35 | $9,332.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,162.28 / $3,890.45 / $5,248.07
| Professional | | $3,162.28 | $3,890.45 | $5,248.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $4,677.35 / $5,370.32
| Professional | | $2,187.76 | $4,677.35 | $5,370.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,467.37 / $3,890.45 / $4,677.35
| Facility | | $3,467.37 | $3,890.45 | $4,677.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $2,344.23 / $3,890.45
| Professional | | $1,621.81 | $2,344.23 | $3,890.45 |