- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,420.17 / $2,420.17 / $8,500.00
| Facility | | $2,420.17 | $2,420.17 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,420.17 / $2,420.17 / $2,521.00
| Professional | | $2,420.17 | $2,420.17 | $2,521.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,632.87 / $5,075.18 / $6,084.04
| Professional | | $4,632.87 | $5,075.18 | $6,084.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,951.85 / $5,667.48 / $7,318.72
| Professional | | $2,951.85 | $5,667.48 | $7,318.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,420.17 / $3,305.62 / $7,260.51
| Facility | | $2,420.17 | $3,305.62 | $7,260.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,506.78 / $4,640.80 / $6,287.10
| Professional | | $2,506.78 | $4,640.80 | $6,287.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,718.62 / $4,942.93 / $6,453.84
| Professional | | $2,718.62 | $4,942.93 | $6,453.84 |