- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,602.59 / $1,602.59 / $8,500.00
| Facility | | $1,602.59 | $1,602.59 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,602.59 / $1,602.59 / $1,922.31
| Professional | | $1,602.59 | $1,602.59 | $1,922.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,034.01 / $2,034.01 / $2,034.01
| Professional | | $2,034.01 | $2,034.01 | $2,034.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,602.59 / $2,388.73 / $4,807.77
| Facility | | $1,602.59 | $2,388.73 | $4,807.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,177.07 / $2,287.34 / $4,144.29
| Professional | | $1,177.07 | $2,287.34 | $4,144.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,372.40 / $2,939.95 / $4,144.29
| Professional | | $1,372.40 | $2,939.95 | $4,144.29 |