- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,650.67 / $2,916.83 / $2,948.92
| Facility | | $1,650.67 | $2,916.83 | $2,948.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,650.67 / $2,916.83 / $3,043.90
| Professional | | $1,650.67 | $2,916.83 | $3,043.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,700.00 / $1,700.00 / $1,700.00
| Professional | | $1,700.00 | $1,700.00 | $1,700.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,196.48 / $2,196.48 / $3,243.50
| Professional | | $2,196.48 | $2,196.48 | $3,243.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,826.34 / $2,613.55 / $4,751.62
| Professional | | $1,826.34 | $2,613.55 | $4,751.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,868.90 / $1,868.90 / $1,868.90
| Professional | | $1,868.90 | $1,868.90 | $1,868.90 |