- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,370.44 / $1,370.44 / $8,500.00
| Facility | | $1,370.44 | $1,370.44 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,234.31 / $1,358.69 / $1,421.97
| Professional | | $1,234.31 | $1,358.69 | $1,421.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,762.92 / $3,039.35 / $3,563.80
| Professional | | $2,762.92 | $3,039.35 | $3,563.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,667.64 / $3,331.72 / $4,437.85
| Professional | | $1,667.64 | $3,331.72 | $4,437.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,370.44 / $1,763.57 / $2,329.75
| Facility | | $1,370.44 | $1,763.57 | $2,329.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,446.83 / $2,567.36 / $3,540.08
| Professional | | $1,446.83 | $2,567.36 | $3,540.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,446.83 / $2,514.07 / $3,183.03
| Professional | | $1,446.83 | $2,514.07 | $3,183.03 |