- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,787.70 / $2,787.70 / $8,500.00
| Facility | | $2,787.70 | $2,787.70 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,787.70 / $2,787.70 / $2,896.01
| Professional | | $2,787.70 | $2,787.70 | $2,896.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,470.53 / $5,950.19 / $7,030.18
| Professional | | $5,470.53 | $5,950.19 | $7,030.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,442.92 / $4,998.62 / $8,068.74
| Professional | | $3,442.92 | $4,998.62 | $8,068.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,787.70 / $3,823.32 / $8,363.10
| Facility | | $2,787.70 | $3,823.32 | $8,363.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,804.79 / $5,265.27 / $7,142.49
| Professional | | $2,804.79 | $5,265.27 | $7,142.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,012.04 / $5,608.06 / $7,142.49
| Professional | | $3,012.04 | $5,608.06 | $7,142.49 |