- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,773.62 / $2,773.62 / $4,326.85
| Facility | | $2,773.62 | $2,773.62 | $4,326.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,773.62 / $2,773.62 / $3,139.03
| Professional | | $2,773.62 | $2,773.62 | $3,139.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,352.96 / $4,675.42 / $8,211.59
| Facility | | $3,352.96 | $4,675.42 | $8,211.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,945.00 / $3,100.00 / $3,317.00
| Professional | | $2,945.00 | $3,100.00 | $3,317.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,558.41 / $3,558.41 / $4,448.01
| Professional | | $3,558.41 | $3,558.41 | $4,448.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,773.62 / $2,773.62 / $5,096.53
| Facility | | $2,773.62 | $2,773.62 | $5,096.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,773.62 / $2,802.82 / $4,200.00
| Professional | | $2,773.62 | $2,802.82 | $4,200.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,226.23 / $1,751.76 / $2,919.60
| Professional | | $1,226.23 | $1,751.76 | $2,919.60 |