- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,492.72 / $1,492.72 / $8,500.00
| Facility | | $1,492.72 | $1,492.72 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,375.95 / $1,492.72 / $1,492.72
| Professional | | $1,375.95 | $1,492.72 | $1,492.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,967.84 / $3,248.89 / $3,894.70
| Professional | | $2,967.84 | $3,248.89 | $3,894.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,866.09 / $3,566.48 / $4,605.58
| Professional | | $1,866.09 | $3,566.48 | $4,605.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,492.72 / $1,905.48 / $4,478.16
| Facility | | $1,492.72 | $1,905.48 | $4,478.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,565.21 / $2,786.26 / $3,860.71
| Professional | | $1,565.21 | $2,786.26 | $3,860.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,632.21 / $3,255.64 / $4,060.79
| Professional | | $1,632.21 | $3,255.64 | $4,060.79 |