- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,490.15 / $1,490.15 / $8,500.00
| Facility | | $1,490.15 | $1,490.15 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,395.10 / $1,490.15 / $1,550.44
| Professional | | $1,395.10 | $1,490.15 | $1,550.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,925.38 / $3,178.91 / $3,755.90
| Professional | | $2,925.38 | $3,178.91 | $3,755.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,869.53 / $2,680.66 / $4,327.10
| Professional | | $1,869.53 | $2,680.66 | $4,327.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,490.15 / $2,011.33 / $4,470.45
| Facility | | $1,490.15 | $2,011.33 | $4,470.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,537.48 / $2,825.79 / $3,820.35
| Professional | | $1,537.48 | $2,825.79 | $3,820.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,805.86 / $3,009.76 / $3,487.54
| Professional | | $1,805.86 | $3,009.76 | $3,487.54 |