- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,261.65 / $2,261.65 / $8,500.00
| Facility | | $2,261.65 | $2,261.65 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,243.44 / $2,261.65 / $3,410.74
| Professional | | $2,243.44 | $2,261.65 | $3,410.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,395.47 / $4,785.54 / $5,654.15
| Professional | | $4,395.47 | $4,785.54 | $5,654.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,774.90 / $4,053.01 / $6,542.33
| Professional | | $2,774.90 | $4,053.01 | $6,542.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,261.65 / $3,090.12 / $6,784.95
| Facility | | $2,261.65 | $3,090.12 | $6,784.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,282.75 / $4,266.00 / $5,798.71
| Professional | | $2,282.75 | $4,266.00 | $5,798.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,499.06 / $4,543.74 / $5,798.71
| Professional | | $2,499.06 | $4,543.74 | $5,798.71 |