- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,744.56 / $1,744.56 / $8,500.00
| Facility | | $1,744.56 | $1,744.56 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,620.96 / $1,733.26 / $2,032.64
| Professional | | $1,620.96 | $1,733.26 | $2,032.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,738.03 / $4,112.01 / $4,821.56
| Professional | | $3,738.03 | $4,112.01 | $4,821.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,115.38 / $4,226.25 / $5,629.38
| Professional | | $2,115.38 | $4,226.25 | $5,629.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,744.56 / $2,280.34 / $3,016.71
| Facility | | $1,744.56 | $2,280.34 | $3,016.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,918.52 / $3,200.68 / $4,455.66
| Professional | | $1,918.52 | $3,200.68 | $4,455.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,918.52 / $3,296.25 / $4,220.74
| Professional | | $1,918.52 | $3,296.25 | $4,220.74 |