- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,357.89 / $1,357.89 / $8,500.00
| Facility | | $1,357.89 | $1,357.89 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,179.97 / $1,350.71 / $1,732.57
| Professional | | $1,179.97 | $1,350.71 | $1,732.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,695.45 / $3,009.76 / $3,540.90
| Professional | | $2,695.45 | $3,009.76 | $3,540.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,564.05 / $3,319.06 / $4,420.99
| Professional | | $1,564.05 | $3,319.06 | $4,420.99 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,357.89 / $1,862.71 / $2,684.38
| Facility | | $1,357.89 | $1,862.71 | $2,684.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,431.67 / $2,491.05 / $3,509.53
| Professional | | $1,431.67 | $2,491.05 | $3,509.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,431.67 / $2,440.62 / $2,930.73
| Professional | | $1,431.67 | $2,440.62 | $2,930.73 |