- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,800.68 / $2,800.68 / $8,500.00
| Facility | | $2,800.68 | $2,800.68 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,489.15 / $2,790.12 / $2,826.10
| Professional | | $2,489.15 | $2,790.12 | $2,826.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,527.81 / $6,080.86 / $7,130.14
| Professional | | $5,527.81 | $6,080.86 | $7,130.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,381.31 / $6,755.42 / $8,998.24
| Professional | | $3,381.31 | $6,755.42 | $8,998.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,800.68 / $3,827.98 / $4,761.16
| Facility | | $2,800.68 | $3,827.98 | $4,761.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,920.37 / $5,137.85 / $7,253.77
| Professional | | $2,920.37 | $5,137.85 | $7,253.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,920.37 / $5,094.07 / $7,253.77
| Professional | | $2,920.37 | $5,094.07 | $7,253.77 |