- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,520.67 / $1,520.67 / $8,500.00
| Facility | | $1,520.67 | $1,520.67 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,310.73 / $1,501.68 / $1,574.07
| Professional | | $1,310.73 | $1,501.68 | $1,574.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,058.15 / $3,364.12 / $3,944.60
| Professional | | $3,058.15 | $3,364.12 | $3,944.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,760.00 / $3,683.62 / $4,906.60
| Professional | | $1,760.00 | $3,683.62 | $4,906.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,312.34 / $1,520.67 / $2,574.40
| Facility | | $1,312.34 | $1,520.67 | $2,574.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,606.35 / $2,789.67 / $3,927.25
| Professional | | $1,606.35 | $2,789.67 | $3,927.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,606.35 / $2,639.39 / $3,282.06
| Professional | | $1,606.35 | $2,639.39 | $3,282.06 |