- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,697.77 / $1,697.77 / $8,500.00
| Facility | | $1,697.77 | $1,697.77 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,557.86 / $1,697.77 / $1,697.77
| Professional | | $1,557.86 | $1,697.77 | $1,697.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,364.80 / $3,681.50 / $4,413.32
| Professional | | $3,364.80 | $3,681.50 | $4,413.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,115.02 / $4,040.26 / $5,217.41
| Professional | | $2,115.02 | $4,040.26 | $5,217.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,697.77 / $2,293.78 / $5,093.31
| Facility | | $1,697.77 | $2,293.78 | $5,093.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,780.66 / $3,114.56 / $4,390.46
| Professional | | $1,780.66 | $3,114.56 | $4,390.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,756.02 / $3,192.76 / $4,390.46
| Professional | | $1,756.02 | $3,192.76 | $4,390.46 |