- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,301.15 / $1,301.15 / $8,500.00
| Facility | | $1,301.15 | $1,301.15 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,255.16 / $1,301.15 / $1,301.15
| Professional | | $1,255.16 | $1,301.15 | $1,301.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,718.86 / $2,962.81 / $3,551.77
| Professional | | $2,718.86 | $2,962.81 | $3,551.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,680.34 / $3,029.79 / $3,912.53
| Professional | | $1,680.34 | $3,029.79 | $3,912.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,301.15 / $1,864.61 / $3,903.45
| Facility | | $1,301.15 | $1,864.61 | $3,903.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,433.06 / $2,446.30 / $3,320.99
| Professional | | $1,433.06 | $2,446.30 | $3,320.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,433.06 / $2,605.56 / $3,320.99
| Professional | | $1,433.06 | $2,605.56 | $3,320.99 |