- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,528.78 / $1,528.78 / $8,500.00
| Facility | | $1,528.78 | $1,528.78 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,417.93 / $1,511.25 / $1,582.64
| Professional | | $1,417.93 | $1,511.25 | $1,582.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,077.21 / $3,385.09 / $3,969.20
| Professional | | $3,077.21 | $3,385.09 | $3,969.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,856.45 / $3,708.94 / $4,940.32
| Professional | | $1,856.45 | $3,708.94 | $4,940.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,528.78 / $2,013.82 / $2,598.92
| Facility | | $1,528.78 | $2,013.82 | $2,598.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,614.65 / $2,858.01 / $3,948.47
| Professional | | $1,614.65 | $2,858.01 | $3,948.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,614.65 / $2,757.01 / $3,299.57
| Professional | | $1,614.65 | $2,757.01 | $3,299.57 |