- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,580.62 / $1,580.62 / $8,500.00
| Facility | | $1,580.62 | $1,580.62 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,297.89 / $1,509.27 / $1,580.62
| Professional | | $1,297.89 | $1,509.27 | $1,580.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,060.12 / $3,366.28 / $3,947.15
| Professional | | $3,060.12 | $3,366.28 | $3,947.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,915.16 / $3,826.24 / $5,096.57
| Professional | | $1,915.16 | $3,826.24 | $5,096.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,580.62 / $1,881.76 / $2,687.05
| Facility | | $1,580.62 | $1,881.76 | $2,687.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.51 / $2,870.62 / $4,114.91
| Professional | | $1,621.51 | $2,870.62 | $4,114.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.51 / $2,870.62 / $3,585.16
| Professional | | $1,621.51 | $2,870.62 | $3,585.16 |