- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,450.65 / $4,797.00 / $4,933.00
| Facility | | $1,450.65 | $4,797.00 | $4,933.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $916.11 / $1,387.28 / $1,450.65
| Professional | | $916.11 | $1,387.28 | $1,450.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,037.69 / $4,797.00 / $4,933.00
| Facility | | $2,037.69 | $4,797.00 | $4,933.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,450.65 / $2,037.69 / $2,597.40
| Professional | | $1,450.65 | $2,037.69 | $2,597.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,906.00 / $4,645.00 / $6,740.00
| Facility | | $1,906.00 | $4,645.00 | $6,740.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,935.25 / $2,511.67 / $3,222.60
| Professional | | $1,935.25 | $2,511.67 | $3,222.60 |