- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,684.74 / $1,684.74 / $8,500.00
| Facility | | $1,684.74 | $1,684.74 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,684.74 / $1,684.74 / $1,968.35
| Professional | | $1,684.74 | $1,684.74 | $1,968.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,917.37 / $3,152.82 / $3,651.28
| Professional | | $2,917.37 | $3,152.82 | $3,651.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,186.52 / $5,424.05 / $8,755.45
| Professional | | $4,186.52 | $5,424.05 | $8,755.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,684.74 / $2,171.31 / $5,054.22
| Facility | | $1,684.74 | $2,171.31 | $5,054.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,549.53 / $3,769.58 / $6,752.08
| Professional | | $1,549.53 | $3,769.58 | $6,752.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,303.63 / $3,223.02 / $6,752.08
| Professional | | $2,303.63 | $3,223.02 | $6,752.08 |