- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,744.26 / $1,744.26 / $8,500.00
| Facility | | $1,744.26 | $1,744.26 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,744.26 / $1,744.26 / $1,823.62
| Professional | | $1,744.26 | $1,744.26 | $1,823.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,434.93 / $3,732.46 / $4,409.92
| Professional | | $3,434.93 | $3,732.46 | $4,409.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,430.94 / $3,157.06 / $5,096.10
| Professional | | $2,430.94 | $3,157.06 | $5,096.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,744.26 / $2,408.61 / $5,232.78
| Facility | | $1,744.26 | $2,408.61 | $5,232.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,831.13 / $3,304.30 / $4,474.35
| Professional | | $1,831.13 | $3,304.30 | $4,474.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,935.68 / $3,519.42 / $4,474.35
| Professional | | $1,935.68 | $3,519.42 | $4,474.35 |