- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,765.44 / $1,765.44 / $8,500.00
| Facility | | $1,765.44 | $1,765.44 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,649.80 / $1,765.44 / $1,765.44
| Professional | | $1,649.80 | $1,765.44 | $1,765.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,686.48 / $4,021.82 / $4,770.74
| Professional | | $3,686.48 | $4,021.82 | $4,770.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,281.56 / $4,099.08 / $5,293.36
| Professional | | $2,281.56 | $4,099.08 | $5,293.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,765.44 / $2,524.98 / $5,296.32
| Facility | | $1,765.44 | $2,524.98 | $5,296.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,947.39 / $3,327.24 / $4,504.01
| Professional | | $1,947.39 | $3,327.24 | $4,504.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,947.39 / $3,543.86 / $4,504.01
| Professional | | $1,947.39 | $3,543.86 | $4,504.01 |