- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,444.36 / $3,444.36 / $8,500.00
| Facility | | $3,444.36 | $3,444.36 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,266.02 / $3,444.36 / $3,444.36
| Professional | | $3,266.02 | $3,444.36 | $3,444.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,136.85 / $7,785.76 / $9,333.42
| Professional | | $7,136.85 | $7,785.76 | $9,333.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,423.59 / $7,847.72 / $10,134.18
| Professional | | $4,423.59 | $7,847.72 | $10,134.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,444.36 / $4,856.42 / $10,333.08
| Facility | | $3,444.36 | $4,856.42 | $10,333.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,829.47 / $6,579.26 / $8,763.70
| Professional | | $3,829.47 | $6,579.26 | $8,763.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,829.47 / $6,628.80 / $8,763.70
| Professional | | $3,829.47 | $6,628.80 | $8,763.70 |