- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,544.15 / $2,544.15 / $8,500.00
| Facility | | $2,544.15 | $2,544.15 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,544.15 / $2,544.15 / $2,640.99
| Professional | | $2,544.15 | $2,544.15 | $2,640.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,989.93 / $5,405.05 / $6,386.10
| Professional | | $4,989.93 | $5,405.05 | $6,386.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,132.90 / $4,573.18 / $7,382.02
| Professional | | $3,132.90 | $4,573.18 | $7,382.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,544.15 / $3,026.49 / $7,632.45
| Facility | | $2,544.15 | $3,026.49 | $7,632.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,453.85 / $4,803.77 / $6,518.76
| Professional | | $2,453.85 | $4,803.77 | $6,518.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,814.09 / $5,116.52 / $6,518.76
| Professional | | $2,814.09 | $5,116.52 | $6,518.76 |