- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,448.79 / $1,448.79 / $8,500.00
| Facility | | $1,448.79 | $1,448.79 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,342.89 / $1,432.13 / $2,280.29
| Professional | | $1,342.89 | $1,432.13 | $2,280.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,915.47 / $3,207.16 / $3,760.56
| Professional | | $2,915.47 | $3,207.16 | $3,760.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,758.03 / $3,512.31 / $4,678.41
| Professional | | $1,758.03 | $3,512.31 | $4,678.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,448.79 / $1,889.19 / $2,462.94
| Facility | | $1,448.79 | $1,889.19 | $2,462.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,530.20 / $2,708.97 / $3,741.84
| Professional | | $1,530.20 | $2,708.97 | $3,741.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,530.20 / $2,657.81 / $3,366.44
| Professional | | $1,530.20 | $2,657.81 | $3,366.44 |