- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,517.07 / $1,517.07 / $8,500.00
| Facility | | $1,517.07 | $1,517.07 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,517.07 / $1,517.07 / $1,558.46
| Professional | | $1,517.07 | $1,517.07 | $1,558.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,985.22 / $3,246.96 / $3,836.30
| Professional | | $2,985.22 | $3,246.96 | $3,836.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,075.10 / $2,688.50 / $4,339.76
| Professional | | $2,075.10 | $2,688.50 | $4,339.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,517.07 / $2,069.21 / $4,551.21
| Facility | | $1,517.07 | $2,069.21 | $4,551.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,657.96 / $3,041.26 / $3,871.00
| Professional | | $1,657.96 | $3,041.26 | $3,871.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,943.56 / $3,239.26 / $3,561.21
| Professional | | $1,943.56 | $3,239.26 | $3,561.21 |