- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,734.52 / $1,734.52 / $8,500.00
| Facility | | $1,734.52 | $1,734.52 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,734.52 / $1,734.52 / $1,813.33
| Professional | | $1,734.52 | $1,734.52 | $1,813.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,415.62 / $3,712.11 / $4,385.89
| Professional | | $3,415.62 | $3,712.11 | $4,385.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,145.63 / $3,136.80 / $5,063.39
| Professional | | $2,145.63 | $3,136.80 | $5,063.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,734.52 / $2,394.06 / $5,203.56
| Facility | | $1,734.52 | $2,394.06 | $5,203.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,750.36 / $3,278.33 / $4,448.67
| Professional | | $1,750.36 | $3,278.33 | $4,448.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,920.47 / $3,308.27 / $4,448.67
| Professional | | $1,920.47 | $3,308.27 | $4,448.67 |