- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,530.22 / $1,530.22 / $8,500.00
| Facility | | $1,530.22 | $1,530.22 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,530.22 / $1,530.22 / $1,573.08
| Professional | | $1,530.22 | $1,530.22 | $1,573.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,022.13 / $3,276.43 / $3,871.12
| Professional | | $3,022.13 | $3,276.43 | $3,871.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,022.49 / $2,713.33 / $4,379.84
| Professional | | $2,022.49 | $2,713.33 | $4,379.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,530.22 / $2,087.94 / $4,590.66
| Facility | | $1,530.22 | $2,087.94 | $4,590.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,672.03 / $2,982.77 / $3,904.78
| Professional | | $1,672.03 | $2,982.77 | $3,904.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,747.33 / $3,176.96 / $3,904.78
| Professional | | $1,747.33 | $3,176.96 | $3,904.78 |