- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,627.46 / $1,627.46 / $9,500.00
| Facility | | $1,627.46 | $1,627.46 | $9,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,515.64 / $1,604.99 / $1,686.73
| Professional | | $1,515.64 | $1,604.99 | $1,686.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,268.55 / $3,595.57 / $4,216.01
| Professional | | $3,268.55 | $3,595.57 | $4,216.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,968.38 / $3,932.57 / $5,238.20
| Professional | | $1,968.38 | $3,932.57 | $5,238.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,627.46 / $2,121.83 / $2,766.68
| Facility | | $1,627.46 | $2,121.83 | $2,766.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,720.39 / $3,026.31 / $4,201.84
| Professional | | $1,720.39 | $3,026.31 | $4,201.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,720.39 / $2,985.58 / $3,784.86
| Professional | | $1,720.39 | $2,985.58 | $3,784.86 |