- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,450.48 / $2,450.48 / $8,500.00
| Facility | | $2,450.48 | $2,450.48 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,349.88 / $2,434.33 / $2,496.44
| Professional | | $2,349.88 | $2,434.33 | $2,496.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,820.31 / $5,302.58 / $6,217.56
| Professional | | $4,820.31 | $5,302.58 | $6,217.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,114.04 / $5,870.17 / $7,819.08
| Professional | | $3,114.04 | $5,870.17 | $7,819.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,450.48 / $3,187.50 / $4,165.82
| Facility | | $2,450.48 | $3,187.50 | $4,165.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,562.00 / $4,495.47 / $6,343.35
| Professional | | $2,562.00 | $4,495.47 | $6,343.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,562.00 / $4,495.47 / $6,090.11
| Professional | | $2,562.00 | $4,495.47 | $6,090.11 |