- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,773.00 / $2,773.00 / $2,773.00
| Facility | | $2,773.00 | $2,773.00 | $2,773.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,773.00 / $2,979.62 / $2,979.62
| Professional | | $2,773.00 | $2,979.62 | $2,979.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,563.69 / $4,213.54 / $4,318.35
| Professional | | $3,563.69 | $4,213.54 | $4,318.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,123.88 / $4,165.10 / $5,237.32
| Professional | | $4,123.88 | $4,165.10 | $5,237.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,483.94 / $2,849.16 / $17,754.05
| Facility | | $1,483.94 | $2,849.16 | $17,754.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,472.06 / $2,536.41 / $3,082.39
| Professional | | $1,472.06 | $2,536.41 | $3,082.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,127.29 / $2,536.41 / $3,036.84
| Professional | | $1,127.29 | $2,536.41 | $3,036.84 |