- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,187.76 / $3,467.37 / $6,025.60
| Facility | | $2,187.76 | $3,467.37 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,511.89 / $2,570.40 / $2,754.23
| Professional | | $2,511.89 | $2,570.40 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $2,754.23 / $6,165.95
| Professional | | $1,905.46 | $2,754.23 | $6,165.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,995.26 / $2,630.27 / $2,630.27
| Facility | | $1,995.26 | $2,630.27 | $2,630.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,630.27 / $2,630.27 / $2,630.27
| Professional | | $2,630.27 | $2,630.27 | $2,630.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,754.23 / $2,754.23 / $2,754.23
| Facility | | $2,754.23 | $2,754.23 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,754.23 / $2,754.23
| Professional | | $2,187.76 | $2,754.23 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $39.81 / $50.12 / $70.79
| Professional | | $39.81 | $50.12 | $70.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,380.38 / $2,290.87
| Facility | | $1,380.38 | $1,380.38 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,454.71 / $2,570.40 / $2,691.53
| Professional | | $2,454.71 | $2,570.40 | $2,691.53 |
- 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 |