- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,796.08 / $1,796.08 / $8,500.00
| Facility | | $1,796.08 | $1,796.08 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,796.08 / $1,796.08 / $1,874.89
| Professional | | $1,796.08 | $1,796.08 | $1,874.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,533.36 / $3,839.80 / $4,536.76
| Professional | | $3,533.36 | $3,839.80 | $4,536.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,503.34 / $3,243.32 / $5,235.34
| Professional | | $2,503.34 | $3,243.32 | $5,235.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,796.08 / $2,475.83 / $5,388.24
| Facility | | $1,796.08 | $2,475.83 | $5,388.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,848.24 / $3,585.60 / $4,606.12
| Professional | | $1,848.24 | $3,585.60 | $4,606.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,100.46 / $3,819.04 / $4,606.12
| Professional | | $2,100.46 | $3,819.04 | $4,606.12 |