- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,358.86 / $1,358.86 / $8,500.00
| Facility | | $1,358.86 | $1,358.86 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,300.51 / $1,315.19 / $1,393.29
| Professional | | $1,300.51 | $1,315.19 | $1,393.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,732.02 / $3,005.35 / $3,523.93
| Professional | | $2,732.02 | $3,005.35 | $3,523.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,644.40 / $3,285.30 / $4,376.03
| Professional | | $1,644.40 | $3,285.30 | $4,376.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,358.86 / $1,680.00 / $2,310.06
| Facility | | $1,358.86 | $1,680.00 | $2,310.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,436.37 / $2,538.40 / $3,508.36
| Professional | | $1,436.37 | $2,538.40 | $3,508.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,436.37 / $2,538.40 / $3,408.28
| Professional | | $1,436.37 | $2,538.40 | $3,408.28 |