- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,949.08 / $1,949.08 / $8,500.00
| Facility | | $1,949.08 | $1,949.08 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.08 / $1,949.08 / $2,042.28
| Professional | | $1,949.08 | $1,949.08 | $2,042.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,741.81 / $4,097.92 / $4,912.51
| Professional | | $3,741.81 | $4,097.92 | $4,912.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,382.38 / $4,594.10 / $5,932.62
| Professional | | $2,382.38 | $4,594.10 | $5,932.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,949.08 / $2,067.41 / $5,847.24
| Facility | | $1,949.08 | $2,067.41 | $5,847.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,015.24 / $3,725.91 / $5,067.37
| Professional | | $2,015.24 | $3,725.91 | $5,067.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,015.24 / $3,968.48 / $5,067.37
| Professional | | $2,015.24 | $3,968.48 | $5,067.37 |