- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,716.40 / $2,716.40 / $8,500.00
| Facility | | $2,716.40 | $2,716.40 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,328.77 / $2,677.03 / $2,818.09
| Professional | | $2,328.77 | $2,677.03 | $2,818.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,440.82 / $5,996.96 / $7,031.75
| Professional | | $5,440.82 | $5,996.96 | $7,031.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,278.67 / $6,550.35 / $8,725.09
| Professional | | $3,278.67 | $6,550.35 | $8,725.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,678.82 / $3,352.31 / $4,617.88
| Facility | | $2,678.82 | $3,352.31 | $4,617.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,873.45 / $4,563.24 / $7,011.35
| Professional | | $2,873.45 | $4,563.24 | $7,011.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,737.94 / $4,563.24 / $6,321.59
| Professional | | $2,737.94 | $4,563.24 | $6,321.59 |