- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,878.72 / $1,878.72 / $8,500.00
| Facility | | $1,878.72 | $1,878.72 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,806.57 / $1,878.72 / $1,878.72
| Professional | | $1,806.57 | $1,878.72 | $1,878.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,921.31 / $4,276.18 / $5,126.21
| Professional | | $3,921.31 | $4,276.18 | $5,126.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,425.98 / $4,353.13 / $5,621.43
| Professional | | $2,425.98 | $4,353.13 | $5,621.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,878.72 / $2,683.56 / $5,636.16
| Facility | | $1,878.72 | $2,683.56 | $5,636.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,074.42 / $3,592.98 / $4,791.38
| Professional | | $2,074.42 | $3,592.98 | $4,791.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,104.80 / $3,826.90 / $4,791.38
| Professional | | $2,104.80 | $3,826.90 | $4,791.38 |