- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,736.83 / $1,736.83 / $8,500.00
| Facility | | $1,736.83 | $1,736.83 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,542.21 / $1,709.57 / $1,763.30
| Professional | | $1,542.21 | $1,709.57 | $1,763.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,440.83 / $3,785.08 / $4,438.21
| Professional | | $3,440.83 | $3,785.08 | $4,438.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,090.46 / $4,176.46 / $5,563.06
| Professional | | $2,090.46 | $4,176.46 | $5,563.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,736.83 / $2,270.75 / $2,952.61
| Facility | | $1,736.83 | $2,270.75 | $2,952.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,822.89 / $3,193.64 / $4,493.77
| Professional | | $1,822.89 | $3,193.64 | $4,493.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,822.89 / $3,108.46 / $4,010.36
| Professional | | $1,822.89 | $3,108.46 | $4,010.36 |