- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,442.91 / $1,442.91 / $8,500.00
| Facility | | $1,442.91 | $1,442.91 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,390.87 / $1,442.91 / $1,442.91
| Professional | | $1,390.87 | $1,442.91 | $1,442.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,014.17 / $3,284.82 / $3,937.78
| Professional | | $3,014.17 | $3,284.82 | $3,937.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,863.02 / $3,355.72 / $4,333.43
| Professional | | $1,863.02 | $3,355.72 | $4,333.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,442.91 / $2,066.21 / $4,328.72
| Facility | | $1,442.91 | $2,066.21 | $4,328.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,590.11 / $2,735.45 / $3,682.43
| Professional | | $1,590.11 | $2,735.45 | $3,682.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,748.12 / $3,275.34 / $3,821.54
| Professional | | $1,748.12 | $3,275.34 | $3,821.54 |