- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,813.80 / $1,813.80 / $8,500.00
| Facility | | $1,813.80 | $1,813.80 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,813.80 / $1,813.80 / $1,861.70
| Professional | | $1,813.80 | $1,813.80 | $1,861.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,566.81 / $3,883.30 / $4,588.14
| Professional | | $3,566.81 | $3,883.30 | $4,588.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,412.98 / $3,210.65 / $5,182.60
| Professional | | $2,412.98 | $3,210.65 | $5,182.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,813.80 / $2,471.52 / $5,441.40
| Facility | | $1,813.80 | $2,471.52 | $5,441.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,983.12 / $3,914.72 / $4,627.31
| Professional | | $1,983.12 | $3,914.72 | $4,627.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,332.64 / $3,981.92 / $4,627.31
| Professional | | $2,332.64 | $3,981.92 | $4,627.31 |