- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,605.71 / $1,605.71 / $8,500.00
| Facility | | $1,605.71 | $1,605.71 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,460.36 / $1,590.29 / $1,666.68
| Professional | | $1,460.36 | $1,590.29 | $1,666.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,175.79 / $3,546.11 / $4,171.89
| Professional | | $3,175.79 | $3,546.11 | $4,171.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.80 / $3,895.44 / $5,188.74
| Professional | | $1,949.80 | $3,895.44 | $5,188.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,605.71 / $2,089.84 / $2,750.75
| Facility | | $1,605.71 | $2,089.84 | $2,750.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,695.85 / $2,973.64 / $4,147.05
| Professional | | $1,695.85 | $2,973.64 | $4,147.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,695.85 / $2,945.67 / $3,730.87
| Professional | | $1,695.85 | $2,945.67 | $3,730.87 |