- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,448.52 / $1,448.52 / $8,500.00
| Facility | | $1,448.52 | $1,448.52 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,448.52 / $1,448.52 / $1,489.12
| Professional | | $1,448.52 | $1,448.52 | $1,489.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,850.11 / $3,103.13 / $3,666.37
| Professional | | $2,850.11 | $3,103.13 | $3,666.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,908.22 / $2,569.56 / $4,147.77
| Professional | | $1,908.22 | $2,569.56 | $4,147.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,448.52 / $1,976.94 / $4,345.56
| Facility | | $1,448.52 | $1,976.94 | $4,345.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,582.53 / $2,934.00 / $3,696.56
| Professional | | $1,582.53 | $2,934.00 | $3,696.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,718.76 / $3,125.02 / $3,696.56
| Professional | | $1,718.76 | $3,125.02 | $3,696.56 |