- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,717.53 / $1,717.53 / $8,500.00
| Facility | | $1,717.53 | $1,717.53 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,708.42 / $1,717.53 / $1,717.53
| Professional | | $1,708.42 | $1,717.53 | $1,717.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,371.87 / $3,681.50 / $4,413.32
| Professional | | $3,371.87 | $3,681.50 | $4,413.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,384.30 / $3,861.37 / $4,986.39
| Professional | | $2,384.30 | $3,861.37 | $4,986.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,717.53 / $2,174.64 / $5,152.59
| Facility | | $1,717.53 | $2,174.64 | $5,152.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,901.72 / $3,246.33 / $4,403.13
| Professional | | $1,901.72 | $3,246.33 | $4,403.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,074.61 / $3,457.68 / $4,403.13
| Professional | | $2,074.61 | $3,457.68 | $4,403.13 |