- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,305.74 / $1,305.74 / $8,500.00
| Facility | | $1,305.74 | $1,305.74 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,074.84 / $1,265.82 / $1,517.41
| Professional | | $1,074.84 | $1,265.82 | $1,517.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,795.14 / $3,074.79 / $3,605.36
| Professional | | $2,795.14 | $3,074.79 | $3,605.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,582.31 / $3,161.25 / $4,210.79
| Professional | | $1,582.31 | $3,161.25 | $4,210.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,305.74 / $1,718.81 / $2,256.01
| Facility | | $1,305.74 | $1,718.81 | $2,256.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,435.28 / $2,395.38 / $3,335.40
| Professional | | $1,435.28 | $2,395.38 | $3,335.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,371.41 / $2,395.38 / $3,216.38
| Professional | | $1,371.41 | $2,395.38 | $3,216.38 |