- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,811.89 / $1,811.89 / $8,500.00
| Facility | | $1,811.89 | $1,811.89 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,811.89 / $1,812.18 / $2,748.76
| Professional | | $1,811.89 | $1,812.18 | $2,748.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,553.48 / $3,842.61 / $4,540.07
| Professional | | $3,553.48 | $3,842.61 | $4,540.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,342.94 / $3,263.58 / $5,268.05
| Professional | | $2,342.94 | $3,263.58 | $5,268.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,811.89 / $2,488.67 / $5,435.67
| Facility | | $1,811.89 | $2,488.67 | $5,435.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,868.54 / $3,436.94 / $4,645.27
| Professional | | $1,868.54 | $3,436.94 | $4,645.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,013.39 / $3,458.39 / $4,645.27
| Professional | | $2,013.39 | $3,458.39 | $4,645.27 |