- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,558.28 / $1,558.28 / $8,500.00
| Facility | | $1,558.28 | $1,558.28 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,558.28 / $1,558.28 / $1,600.82
| Professional | | $1,558.28 | $1,558.28 | $1,600.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,077.65 / $3,335.36 / $3,940.75
| Professional | | $3,077.65 | $3,335.36 | $3,940.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,083.80 / $2,761.69 / $4,457.89
| Professional | | $2,083.80 | $2,761.69 | $4,457.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,558.28 / $2,125.69 / $4,674.84
| Facility | | $1,558.28 | $2,125.69 | $4,674.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,703.07 / $3,253.03 / $3,976.13
| Professional | | $1,703.07 | $3,253.03 | $3,976.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.65 / $3,363.24 / $3,976.13
| Professional | | $1,905.65 | $3,363.24 | $3,976.13 |