- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,632.54 / $3,632.54 / $4,299.54
| Facility | | $3,632.54 | $3,632.54 | $4,299.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,162.16 / $1,651.52 / $3,177.40
| Professional | | $1,162.16 | $1,651.52 | $3,177.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,459.27 / $1,462.63 / $1,694.73
| Professional | | $1,459.27 | $1,462.63 | $1,694.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $682.00 / $722.49 / $1,575.38
| Facility | | $682.00 | $722.49 | $1,575.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,116.16 / $1,454.47 / $2,445.17
| Professional | | $1,116.16 | $1,454.47 | $2,445.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,405.70 / $1,616.56 / $2,108.55
| Professional | | $1,405.70 | $1,616.56 | $2,108.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,386.00 / $1,386.00 / $1,386.00
| Facility | | $1,386.00 | $1,386.00 | $1,386.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,010.98 / $1,290.61 / $2,570.31
| Professional | | $1,010.98 | $1,290.61 | $2,570.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,085.46 / $1,479.38 / $1,616.55
| Professional | | $1,085.46 | $1,479.38 | $1,616.55 |