- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,436.05 / $1,436.05 / $8,500.00
| Facility | | $1,436.05 | $1,436.05 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,344.18 / $1,436.05 / $1,436.05
| Professional | | $1,344.18 | $1,436.05 | $1,436.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,857.83 / $3,111.49 / $3,729.99
| Professional | | $2,857.83 | $3,111.49 | $3,729.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,787.84 / $3,300.99 / $4,262.75
| Professional | | $1,787.84 | $3,300.99 | $4,262.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,436.05 / $1,813.19 / $4,308.14
| Facility | | $1,436.05 | $1,813.19 | $4,308.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,546.08 / $2,879.32 / $3,686.21
| Professional | | $1,546.08 | $2,879.32 | $3,686.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,978.00 / $1,978.00 / $1,978.00
| Facility | | $1,978.00 | $1,978.00 | $1,978.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,546.08 / $2,879.32 / $3,686.21
| Professional | | $1,546.08 | $2,879.32 | $3,686.21 |