- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,451.22 / $1,451.22 / $8,500.00
| Facility | | $1,451.22 | $1,451.22 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,403.22 / $1,451.22 / $1,451.22
| Professional | | $1,403.22 | $1,451.22 | $1,451.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,035.39 / $3,309.47 / $3,967.34
| Professional | | $3,035.39 | $3,309.47 | $3,967.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,876.83 / $3,384.31 / $4,370.35
| Professional | | $1,876.83 | $3,384.31 | $4,370.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,451.22 / $2,082.71 / $4,353.66
| Facility | | $1,451.22 | $2,082.71 | $4,353.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,598.05 / $2,758.81 / $3,704.64
| Professional | | $1,598.05 | $2,758.81 | $3,704.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,598.05 / $2,938.42 / $3,704.64
| Professional | | $1,598.05 | $2,938.42 | $3,704.64 |