- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,476.71 / $2,806.95 / $3,602.51
| Facility | | $2,476.71 | $2,806.95 | $3,602.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,500.00 / $1,500.00 / $1,500.00
| Professional | | $1,500.00 | $1,500.00 | $1,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,602.51 / $3,602.51 / $3,602.51
| Professional | | $3,602.51 | $3,602.51 | $3,602.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,829.20 / $3,143.55 / $3,752.61
| Professional | | $2,829.20 | $3,143.55 | $3,752.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,302.30 / $3,602.51 / $4,202.93
| Professional | | $3,302.30 | $3,602.51 | $4,202.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,002.09 / $3,602.51 / $4,503.14
| Professional | | $3,002.09 | $3,602.51 | $4,503.14 |