- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,486.04 / $1,486.04 / $8,500.00
| Facility | | $1,486.04 | $1,486.04 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,306.52 / $1,486.04 / $1,548.81
| Professional | | $1,306.52 | $1,486.04 | $1,548.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,917.66 / $3,172.59 / $3,748.44
| Professional | | $2,917.66 | $3,172.59 | $3,748.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,064.51 / $2,674.78 / $4,317.60
| Professional | | $2,064.51 | $2,674.78 | $4,317.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,486.04 / $2,043.12 / $4,458.12
| Facility | | $1,486.04 | $2,043.12 | $4,458.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,517.59 / $2,967.48 / $3,810.63
| Professional | | $1,517.59 | $2,967.48 | $3,810.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,738.37 / $3,207.32 / $3,810.63
| Professional | | $1,738.37 | $3,207.32 | $3,810.63 |