- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,477.66 / $1,477.66 / $8,500.00
| Facility | | $1,477.66 | $1,477.66 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,477.66 / $1,477.66 / $1,547.85
| Professional | | $1,477.66 | $1,477.66 | $1,547.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,924.00 / $3,165.57 / $3,740.14
| Professional | | $2,924.00 | $3,165.57 | $3,740.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,070.56 / $2,682.62 / $4,330.26
| Professional | | $2,070.56 | $2,682.62 | $4,330.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,477.66 / $2,045.13 / $4,432.97
| Facility | | $1,477.66 | $2,045.13 | $4,432.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,537.48 / $2,798.37 / $3,791.89
| Professional | | $1,537.48 | $2,798.37 | $3,791.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,639.31 / $2,980.56 / $3,791.89
| Professional | | $1,639.31 | $2,980.56 | $3,791.89 |