- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,027.05 / $2,027.05 / $8,500.00
| Facility | | $2,027.05 | $2,027.05 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.53 / $2,027.05 / $2,027.05
| Professional | | $1,905.53 | $2,027.05 | $2,027.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,906.52 / $4,243.77 / $5,087.35
| Professional | | $3,906.52 | $4,243.77 | $5,087.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,457.48 / $4,680.68 / $6,044.43
| Professional | | $2,457.48 | $4,680.68 | $6,044.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,027.05 / $2,811.84 / $6,081.15
| Facility | | $2,027.05 | $2,811.84 | $6,081.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,129.65 / $3,790.39 / $5,242.49
| Professional | | $2,129.65 | $3,790.39 | $5,242.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,220.44 / $3,790.39 / $5,242.49
| Professional | | $2,220.44 | $3,790.39 | $5,242.49 |