- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,413.43 / $1,413.43 / $8,500.00
| Facility | | $1,413.43 | $1,413.43 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,366.40 / $1,366.85 / $1,448.70
| Professional | | $1,366.40 | $1,366.85 | $1,448.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,807.13 / $3,114.30 / $3,663.88
| Professional | | $2,807.13 | $3,114.30 | $3,663.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,709.45 / $3,415.26 / $4,549.14
| Professional | | $1,709.45 | $3,415.26 | $4,549.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,413.43 / $1,746.71 / $2,402.83
| Facility | | $1,413.43 | $1,746.71 | $2,402.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,494.47 / $2,640.02 / $3,648.94
| Professional | | $1,494.47 | $2,640.02 | $3,648.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,494.47 / $2,640.02 / $3,648.94
| Professional | | $1,494.47 | $2,640.02 | $3,648.94 |