- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,785.23 / $2,785.23 / $8,500.00
| Facility | | $2,785.23 | $2,785.23 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,550.40 / $2,721.53 / $2,883.95
| Professional | | $2,550.40 | $2,721.53 | $2,883.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,557.40 / $6,113.42 / $7,168.30
| Professional | | $5,557.40 | $6,113.42 | $7,168.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,328.51 / $6,649.93 / $8,857.73
| Professional | | $3,328.51 | $6,649.93 | $8,857.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,785.23 / $3,417.41 / $4,734.89
| Facility | | $2,785.23 | $3,417.41 | $4,734.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,952.13 / $5,169.18 / $7,183.28
| Professional | | $2,952.13 | $5,169.18 | $7,183.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,952.13 / $5,169.18 / $7,183.28
| Professional | | $2,952.13 | $5,169.18 | $7,183.28 |