- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,796.61 / $1,796.61 / $8,500.00
| Facility | | $1,796.61 | $1,796.61 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,682.09 / $1,784.08 / $2,095.62
| Professional | | $1,682.09 | $1,784.08 | $2,095.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,837.97 / $4,221.96 / $4,950.47
| Professional | | $3,837.97 | $4,221.96 | $4,950.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,161.84 / $4,319.08 / $5,753.03
| Professional | | $2,161.84 | $4,319.08 | $5,753.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,796.61 / $2,416.82 / $3,180.48
| Facility | | $1,796.61 | $2,416.82 | $3,180.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,980.24 / $3,409.13 / $4,584.82
| Professional | | $1,980.24 | $3,409.13 | $4,584.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,980.24 / $3,375.13 / $4,584.82
| Professional | | $1,980.24 | $3,375.13 | $4,584.82 |