- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,590.31 / $1,590.31 / $9,500.00
| Facility | | $1,590.31 | $1,590.31 | $9,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,440.05 / $1,562.64 / $1,646.82
| Professional | | $1,440.05 | $1,562.64 | $1,646.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,187.03 / $3,505.89 / $4,110.83
| Professional | | $3,187.03 | $3,505.89 | $4,110.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,915.58 / $3,827.09 / $5,097.68
| Professional | | $1,915.58 | $3,827.09 | $5,097.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,590.31 / $2,072.23 / $2,703.53
| Facility | | $1,590.31 | $2,072.23 | $2,703.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,682.50 / $2,917.42 / $4,104.47
| Professional | | $1,682.50 | $2,917.42 | $4,104.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,682.50 / $2,917.42 / $4,104.47
| Professional | | $1,682.50 | $2,917.42 | $4,104.47 |