- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,818.67 / $2,818.67 / $8,500.00
| Facility | | $2,818.67 | $2,818.67 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,572.40 / $2,768.84 / $2,919.94
| Professional | | $2,572.40 | $2,768.84 | $2,919.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,647.48 / $6,212.50 / $7,284.50
| Professional | | $5,647.48 | $6,212.50 | $7,284.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,392.29 / $6,777.36 / $9,027.45
| Professional | | $3,392.29 | $6,777.36 | $9,027.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,818.67 / $3,767.14 / $4,744.37
| Facility | | $2,818.67 | $3,767.14 | $4,744.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,983.53 / $5,249.86 / $7,273.61
| Professional | | $2,983.53 | $5,249.86 | $7,273.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,120.35 / $5,249.86 / $7,273.61
| Professional | | $3,120.35 | $5,249.86 | $7,273.61 |