- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $708.02 / $2,527.71 / $4,155.05
| Facility | | $708.02 | $2,527.71 | $4,155.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,691.84 / $2,105.41 / $4,155.05
| Professional | | $1,691.84 | $2,105.41 | $4,155.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,384.12 / $3,384.12 / $3,384.12
| Facility | | $3,384.12 | $3,384.12 | $3,384.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,384.12 / $3,384.12 / $3,384.12
| Professional | | $3,384.12 | $3,384.12 | $3,384.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,691.84 / $3,975.95 / $4,200.00
| Facility | | $1,691.84 | $3,975.95 | $4,200.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,200.00 / $4,200.00 / $24,051.83
| Professional | | $4,200.00 | $4,200.00 | $24,051.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,200.00 / $4,200.00 / $4,727.93
| Professional | | $4,200.00 | $4,200.00 | $4,727.93 |