- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,413.41 / $1,413.41 / $8,500.00
| Facility | | $1,413.41 | $1,413.41 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,334.66 / $1,420.08 / $2,172.75
| Professional | | $1,334.66 | $1,420.08 | $2,172.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,787.70 / $3,029.47 / $3,579.34
| Professional | | $2,787.70 | $3,029.47 | $3,579.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,982.80 / $2,568.91 / $4,146.71
| Professional | | $1,982.80 | $2,568.91 | $4,146.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,413.41 / $1,957.77 / $4,240.22
| Facility | | $1,413.41 | $1,957.77 | $4,240.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,470.64 / $2,677.84 / $3,627.72
| Professional | | $1,470.64 | $2,677.84 | $3,627.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,568.70 / $2,852.18 / $3,627.72
| Professional | | $1,568.70 | $2,852.18 | $3,627.72 |