- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,713.51 / $2,713.51 / $8,500.00
| Facility | | $2,713.51 | $2,713.51 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,119.01 / $2,671.33 / $2,812.98
| Professional | | $2,119.01 | $2,671.33 | $2,812.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,442.33 / $5,986.83 / $7,019.88
| Professional | | $5,442.33 | $5,986.83 | $7,019.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,272.76 / $6,538.54 / $8,709.35
| Professional | | $3,272.76 | $6,538.54 | $8,709.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,658.40 / $3,346.65 / $4,612.97
| Facility | | $2,658.40 | $3,346.65 | $4,612.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,870.57 / $5,062.03 / $7,003.71
| Professional | | $2,870.57 | $5,062.03 | $7,003.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,870.57 / $5,062.03 / $6,315.25
| Professional | | $2,870.57 | $5,062.03 | $6,315.25 |