- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,473.41 / $1,473.41 / $8,500.00
| Facility | | $1,473.41 | $1,473.41 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $974.75 / $1,473.41 / $1,616.59
| Professional | | $974.75 | $1,473.41 | $1,616.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,917.37 / $3,152.82 / $3,651.28
| Professional | | $2,917.37 | $3,152.82 | $3,651.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,283.42 / $2,958.39 / $4,775.42
| Professional | | $2,283.42 | $2,958.39 | $4,775.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,473.41 / $2,171.31 / $4,420.22
| Facility | | $1,473.41 | $2,171.31 | $4,420.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,459.84 / $2,633.34 / $3,683.06
| Professional | | $1,459.84 | $2,633.34 | $3,683.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,605.06 / $2,804.78 / $3,683.06
| Professional | | $1,605.06 | $2,804.78 | $3,683.06 |