- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,711.83 / $1,711.83 / $8,500.00
| Facility | | $1,711.83 | $1,711.83 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,656.28 / $1,711.83 / $2,406.53
| Professional | | $1,656.28 | $1,711.83 | $2,406.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,171.15 / $3,451.12 / $4,077.53
| Professional | | $3,171.15 | $3,451.12 | $4,077.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,204.73 / $2,856.45 / $4,610.85
| Professional | | $2,204.73 | $2,856.45 | $4,610.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,711.83 / $2,198.21 / $5,135.49
| Facility | | $1,711.83 | $2,198.21 | $5,135.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,820.79 / $3,263.27 / $4,379.49
| Professional | | $1,820.79 | $3,263.27 | $4,379.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,911.65 / $3,475.72 / $4,379.49
| Professional | | $1,911.65 | $3,475.72 | $4,379.49 |