- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,818.53 / $2,818.53 / $8,500.00
| Facility | | $2,818.53 | $2,818.53 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,818.53 / $2,818.53 / $2,919.27
| Professional | | $2,818.53 | $2,818.53 | $2,919.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,388.18 / $5,906.61 / $7,080.73
| Professional | | $5,388.18 | $5,906.61 | $7,080.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,434.13 / $6,561.96 / $8,473.81
| Professional | | $3,434.13 | $6,561.96 | $8,473.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,818.53 / $3,039.99 / $8,455.59
| Facility | | $2,818.53 | $3,039.99 | $8,455.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,926.14 / $5,415.73 / $7,314.35
| Professional | | $2,926.14 | $5,415.73 | $7,314.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,172.58 / $6,086.37 / $7,314.35
| Professional | | $3,172.58 | $6,086.37 | $7,314.35 |