- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,592.48 / $1,592.48 / $8,500.00
| Facility | | $1,592.48 | $1,592.48 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,592.48 / $1,592.48 / $1,635.03
| Professional | | $1,592.48 | $1,592.48 | $1,635.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,131.26 / $3,406.22 / $4,024.47
| Professional | | $3,131.26 | $3,406.22 | $4,024.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,129.66 / $2,820.51 / $4,552.84
| Professional | | $2,129.66 | $2,820.51 | $4,552.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,592.48 / $2,170.69 / $4,777.43
| Facility | | $1,592.48 | $2,170.69 | $4,777.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,740.24 / $3,201.08 / $4,063.53
| Professional | | $1,740.24 | $3,201.08 | $4,063.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,537.29 / $3,409.48 / $3,738.02
| Professional | | $2,537.29 | $3,409.48 | $3,738.02 |