- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,284.45 / $1,400.00 / $2,600.00
| Facility | | $1,284.45 | $1,400.00 | $2,600.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,259.77 / $1,348.41 / $1,943.49
| Professional | | $1,259.77 | $1,348.41 | $1,943.49 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,376.33 / $1,542.40 / $1,680.47
| Facility | | $1,376.33 | $1,542.40 | $1,680.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $766.50 / $1,493.75 / $1,493.75
| Professional | | $766.50 | $1,493.75 | $1,493.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,471.08 / $1,471.08 / $1,471.08
| Facility | | $1,471.08 | $1,471.08 | $1,471.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,253.97 / $1,867.18 / $3,760.47
| Professional | | $1,253.97 | $1,867.18 | $3,760.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.16 / $1,449.87 / $2,066.98
| Professional | | $1,000.16 | $1,449.87 | $2,066.98 |