- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,870.42 / $1,870.42 / $8,500.00
| Facility | | $1,870.42 | $1,870.42 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,796.09 / $1,870.42 / $1,870.42
| Professional | | $1,796.09 | $1,870.42 | $1,870.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,900.72 / $4,255.04 / $5,100.85
| Professional | | $3,900.72 | $4,255.04 | $5,100.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,413.88 / $4,326.17 / $5,586.62
| Professional | | $2,413.88 | $4,326.17 | $5,586.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,870.42 / $2,667.80 / $5,611.26
| Facility | | $1,870.42 | $2,667.80 | $5,611.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,066.13 / $3,558.51 / $4,769.45
| Professional | | $2,066.13 | $3,558.51 | $4,769.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,066.13 / $3,790.18 / $4,769.45
| Professional | | $2,066.13 | $3,790.18 | $4,769.45 |