- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,276.13 / $2,276.13 / $8,500.00
| Facility | | $2,276.13 | $2,276.13 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,248.86 / $2,276.13 / $2,276.13
| Professional | | $2,248.86 | $2,276.13 | $2,276.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,445.01 / $4,857.47 / $5,823.04
| Professional | | $4,445.01 | $4,857.47 | $5,823.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,799.36 / $5,075.24 / $6,553.94
| Professional | | $2,799.36 | $5,075.24 | $6,553.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,276.13 / $2,606.92 / $6,828.39
| Facility | | $2,276.13 | $2,606.92 | $6,828.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,457.34 / $4,287.47 / $5,833.22
| Professional | | $2,457.34 | $4,287.47 | $5,833.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,457.34 / $4,566.60 / $5,833.22
| Professional | | $2,457.34 | $4,566.60 | $5,833.22 |