- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,773.62 / $2,773.62 / $4,326.85
| Facility | | $2,773.62 | $2,773.62 | $4,326.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,496.26 / $2,773.62 / $2,773.62
| Professional | | $2,496.26 | $2,773.62 | $2,773.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,945.00 / $1,945.00 / $2,047.37
| Facility | | $1,945.00 | $1,945.00 | $2,047.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,945.00 / $2,047.37 / $2,277.29
| Professional | | $1,945.00 | $2,047.37 | $2,277.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,558.41 / $4,448.01 / $6,569.10
| Professional | | $3,558.41 | $4,448.01 | $6,569.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,773.62 / $2,773.62 / $5,096.53
| Facility | | $2,773.62 | $2,773.62 | $5,096.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,773.62 / $2,802.82 / $3,503.52
| Professional | | $2,773.62 | $2,802.82 | $3,503.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,919.60 / $2,919.60 / $3,503.52
| Facility | | $2,919.60 | $2,919.60 | $3,503.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,226.23 / $1,751.76 / $3,795.48
| Professional | | $1,226.23 | $1,751.76 | $3,795.48 |