- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,635.67 / $1,635.67 / $8,500.00
| Facility | | $1,635.67 | $1,635.67 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,635.67 / $1,635.67 / $1,680.10
| Professional | | $1,635.67 | $1,635.67 | $1,680.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,218.11 / $3,501.63 / $4,137.21
| Professional | | $3,218.11 | $3,501.63 | $4,137.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,189.52 / $2,897.62 / $4,677.32
| Professional | | $2,189.52 | $2,897.62 | $4,677.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,635.67 / $2,230.58 / $4,907.01
| Facility | | $1,635.67 | $2,230.58 | $4,907.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,787.52 / $3,134.58 / $4,173.59
| Professional | | $1,787.52 | $3,134.58 | $4,173.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,853.02 / $3,338.66 / $4,173.59
| Professional | | $1,853.02 | $3,338.66 | $4,173.59 |