- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,733.73 / $1,733.73 / $8,500.00
| Facility | | $1,733.73 | $1,733.73 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,733.73 / $1,733.73 / $1,779.26
| Professional | | $1,733.73 | $1,733.73 | $1,779.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,408.55 / $3,710.01 / $4,383.41
| Professional | | $3,408.55 | $3,710.01 | $4,383.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,368.66 / $3,068.84 / $4,953.68
| Professional | | $2,368.66 | $3,068.84 | $4,953.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,733.73 / $2,362.25 / $5,201.18
| Facility | | $1,733.73 | $2,362.25 | $5,201.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,895.43 / $3,311.68 / $4,423.22
| Professional | | $1,895.43 | $3,311.68 | $4,423.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,116.37 / $3,354.91 / $4,423.22
| Professional | | $2,116.37 | $3,354.91 | $4,423.22 |