- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,614.63 / $1,614.63 / $8,500.00
| Facility | | $1,614.63 | $1,614.63 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,614.63 / $1,614.63 / $1,688.55
| Professional | | $1,614.63 | $1,614.63 | $1,688.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,160.85 / $3,428.67 / $4,051.00
| Professional | | $3,160.85 | $3,428.67 | $4,051.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,240.19 / $2,919.18 / $4,712.13
| Professional | | $2,240.19 | $2,919.18 | $4,712.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,614.63 / $2,223.94 / $4,843.89
| Facility | | $1,614.63 | $2,223.94 | $4,843.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,679.93 / $3,064.94 / $4,141.34
| Professional | | $1,679.93 | $3,064.94 | $4,141.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,795.46 / $3,264.48 / $4,141.34
| Professional | | $1,795.46 | $3,264.48 | $4,141.34 |