- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,476.54 / $1,476.54 / $8,500.00
| Facility | | $1,476.54 | $1,476.54 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,409.92 / $1,476.54 / $1,476.54
| Professional | | $1,409.92 | $1,476.54 | $1,476.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,984.57 / $3,237.61 / $3,881.18
| Professional | | $2,984.57 | $3,237.61 | $3,881.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,161.35 / $3,500.31 / $4,520.14
| Professional | | $2,161.35 | $3,500.31 | $4,520.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,476.54 / $1,846.97 / $4,429.62
| Facility | | $1,476.54 | $1,846.97 | $4,429.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,577.84 / $2,763.32 / $3,801.17
| Professional | | $1,577.84 | $2,763.32 | $3,801.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,577.84 / $2,943.22 / $3,801.17
| Professional | | $1,577.84 | $2,943.22 | $3,801.17 |