- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,641.24 / $1,641.24 / $8,500.00
| Facility | | $1,641.24 | $1,641.24 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,536.09 / $1,643.07 / $1,660.88
| Professional | | $1,536.09 | $1,643.07 | $1,660.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,179.02 / $3,549.72 / $4,176.14
| Professional | | $3,179.02 | $3,549.72 | $4,176.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,989.93 / $3,975.61 / $5,295.53
| Professional | | $1,989.93 | $3,975.61 | $5,295.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,641.24 / $1,992.21 / $2,790.11
| Facility | | $1,641.24 | $1,992.21 | $2,790.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,707.04 / $3,112.02 / $4,255.70
| Professional | | $1,707.04 | $3,112.02 | $4,255.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,707.04 / $3,021.46 / $3,755.49
| Professional | | $1,707.04 | $3,021.46 | $3,755.49 |