- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,811.29 / $2,811.29 / $8,500.00
| Facility | | $2,811.29 | $2,811.29 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,099.44 / $2,760.59 / $2,912.07
| Professional | | $2,099.44 | $2,760.59 | $2,912.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,629.72 / $6,192.98 / $7,261.60
| Professional | | $5,629.72 | $6,192.98 | $7,261.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,380.89 / $6,754.58 / $8,997.11
| Professional | | $3,380.89 | $6,754.58 | $8,997.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,811.29 / $3,705.93 / $4,779.18
| Facility | | $2,811.29 | $3,705.93 | $4,779.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,975.59 / $4,830.78 / $7,254.58
| Professional | | $2,975.59 | $4,830.78 | $7,254.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,898.47 / $4,830.78 / $6,546.30
| Professional | | $2,898.47 | $4,830.78 | $6,546.30 |