- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,868.76 / $3,868.76 / $5,573.36
| Facility | | $3,868.76 | $3,868.76 | $5,573.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,500.52 / $4,180.02 / $4,180.02
| Professional | | $1,500.52 | $4,180.02 | $4,180.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,090.01 / $2,271.14 / $8,360.04
| Facility | | $2,090.01 | $2,271.14 | $8,360.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,597.86 / $2,463.13 / $3,547.65
| Professional | | $1,597.86 | $2,463.13 | $3,547.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,014.98 / $4,180.02 / $4,598.02
| Facility | | $2,014.98 | $4,180.02 | $4,598.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,143.60 / $2,143.60 / $2,572.32
| Professional | | $2,143.60 | $2,143.60 | $2,572.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,639.85 / $1,929.24 / $4,180.02
| Professional | | $1,639.85 | $1,929.24 | $4,180.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,215.40 / $4,287.20 / $7,716.96
| Facility | | $3,215.40 | $4,287.20 | $7,716.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,822.06 / $3,770.62 / $3,770.62
| Professional | | $1,822.06 | $3,770.62 | $3,770.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $252.88 / $900.31 / $1,286.16
| Professional | | $252.88 | $900.31 | $1,286.16 |