- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,381.68 / $1,381.68 / $8,500.00
| Facility | | $1,381.68 | $1,381.68 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,381.68 / $1,381.68 / $1,447.16
| Professional | | $1,381.68 | $1,381.68 | $1,447.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,707.28 / $2,936.85 / $3,469.92
| Professional | | $2,707.28 | $2,936.85 | $3,469.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,718.54 / $2,503.56 / $4,041.23
| Professional | | $1,718.54 | $2,503.56 | $4,041.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,381.68 / $1,906.26 / $4,145.04
| Facility | | $1,381.68 | $1,906.26 | $4,145.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,387.47 / $2,618.44 / $3,544.80
| Professional | | $1,387.47 | $2,618.44 | $3,544.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,533.91 / $2,788.92 / $3,544.80
| Professional | | $1,533.91 | $2,788.92 | $3,544.80 |