- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,417.47 / $3,417.47 / $8,500.00
| Facility | | $3,417.47 | $3,417.47 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,397.04 / $3,417.47 / $3,417.47
| Professional | | $3,397.04 | $3,417.47 | $3,417.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,708.37 / $7,329.19 / $8,786.09
| Professional | | $6,708.37 | $7,329.19 | $8,786.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,220.59 / $7,676.17 / $9,912.66
| Professional | | $4,220.59 | $7,676.17 | $9,912.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,417.47 / $3,653.42 / $10,252.41
| Facility | | $3,417.47 | $3,653.42 | $10,252.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,691.24 / $6,463.35 / $8,757.70
| Professional | | $3,691.24 | $6,463.35 | $8,757.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,786.28 / $6,884.14 / $8,757.70
| Professional | | $3,786.28 | $6,884.14 | $8,757.70 |