- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,806.72 / $1,806.72 / $8,500.00
| Facility | | $1,806.72 | $1,806.72 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,692.07 / $1,806.72 / $1,806.72
| Professional | | $1,692.07 | $1,806.72 | $1,806.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,456.80 / $3,762.53 / $4,510.45
| Professional | | $3,456.80 | $3,762.53 | $4,510.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,173.26 / $4,188.12 / $5,408.34
| Professional | | $2,173.26 | $4,188.12 | $5,408.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,806.72 / $2,469.36 / $5,420.16
| Facility | | $1,806.72 | $2,469.36 | $5,420.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,878.46 / $3,417.22 / $4,679.37
| Professional | | $1,878.46 | $3,417.22 | $4,679.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,878.46 / $3,639.70 / $4,679.37
| Professional | | $1,878.46 | $3,639.70 | $4,679.37 |