- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,500.31 / $1,500.31 / $8,500.00
| Facility | | $1,500.31 | $1,500.31 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,500.31 / $1,500.31 / $1,568.66
| Professional | | $1,500.31 | $1,500.31 | $1,568.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,955.62 / $3,210.48 / $3,793.20
| Professional | | $2,955.62 | $3,210.48 | $3,793.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,096.29 / $2,715.95 / $4,384.06
| Professional | | $2,096.29 | $2,715.95 | $4,384.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,500.31 / $2,072.44 / $4,500.93
| Facility | | $1,500.31 | $2,072.44 | $4,500.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,560.56 / $2,840.66 / $3,848.84
| Professional | | $1,560.56 | $2,840.66 | $3,848.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,664.08 / $3,025.60 / $3,848.84
| Professional | | $1,664.08 | $3,025.60 | $3,848.84 |