- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,700.76 / $1,700.76 / $8,500.00
| Facility | | $1,700.76 | $1,700.76 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,681.75 / $1,700.76 / $1,767.20
| Professional | | $1,681.75 | $1,700.76 | $1,767.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,336.49 / $3,627.92 / $4,286.42
| Professional | | $3,336.49 | $3,627.92 | $4,286.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,321.42 / $3,053.15 / $4,928.38
| Professional | | $2,321.42 | $3,053.15 | $4,928.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,700.76 / $2,333.67 / $5,102.28
| Facility | | $1,700.76 | $2,333.67 | $5,102.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,794.92 / $3,222.82 / $4,359.10
| Professional | | $1,794.92 | $3,222.82 | $4,359.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,835.88 / $3,432.64 / $4,359.10
| Professional | | $1,835.88 | $3,432.64 | $4,359.10 |