- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,316.09 / $3,316.09 / $8,500.00
| Facility | | $3,316.09 | $3,316.09 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,108.01 / $3,316.09 / $4,952.81
| Professional | | $3,108.01 | $3,316.09 | $4,952.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,422.07 / $6,974.51 / $8,240.43
| Professional | | $6,422.07 | $6,974.51 | $8,240.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,544.64 / $5,888.04 / $9,504.42
| Professional | | $4,544.64 | $5,888.04 | $9,504.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,316.09 / $4,128.22 / $9,948.27
| Facility | | $3,316.09 | $4,128.22 | $9,948.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,588.75 / $6,181.12 / $8,490.86
| Professional | | $3,588.75 | $6,181.12 | $8,490.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,903.39 / $6,217.00 / $8,490.86
| Professional | | $3,903.39 | $6,217.00 | $8,490.86 |