- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,981.07 / $4,570.88 / $7,585.78
| Facility | | $3,981.07 | $4,570.88 | $7,585.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $1,288.25 / $3,630.78
| Professional | | $977.24 | $1,288.25 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,230.27 / $1,584.89
| Professional | | $1,122.02 | $1,230.27 | $1,584.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,548.82 / $2,951.21
| Professional | | $1,047.13 | $1,548.82 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,202.26 / $2,187.76
| Professional | | $1,071.52 | $1,202.26 | $2,187.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,884.03 / $2,884.03 / $2,884.03
| Facility | | $2,884.03 | $2,884.03 | $2,884.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,380.38 / $2,344.23
| Professional | | $1,000.00 | $1,380.38 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,380.38 / $1,584.89
| Professional | | $1,096.48 | $1,380.38 | $1,584.89 |