- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,700.63 / $1,700.63 / $8,500.00
| Facility | | $1,700.63 | $1,700.63 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,542.95 / $1,675.73 / $1,726.12
| Professional | | $1,542.95 | $1,675.73 | $1,726.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,357.94 / $3,701.17 / $4,339.83
| Professional | | $3,357.94 | $3,701.17 | $4,339.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,045.26 / $4,086.16 / $5,442.78
| Professional | | $2,045.26 | $4,086.16 | $5,442.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,700.63 / $2,193.73 / $2,891.07
| Facility | | $1,700.63 | $2,193.73 | $2,891.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,784.27 / $3,111.26 / $4,400.71
| Professional | | $1,784.27 | $3,111.26 | $4,400.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,711.19 / $2,800.13 / $3,767.08
| Professional | | $1,711.19 | $2,800.13 | $3,767.08 |