- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,974.72 / $2,974.72 / $8,500.00
| Facility | | $2,974.72 | $2,974.72 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,974.72 / $2,974.72 / $3,086.52
| Professional | | $2,974.72 | $2,974.72 | $3,086.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,792.86 / $6,291.86 / $7,433.88
| Professional | | $5,792.86 | $6,291.86 | $7,433.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,656.50 / $5,320.14 / $8,587.74
| Professional | | $3,656.50 | $5,320.14 | $8,587.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,974.72 / $4,062.89 / $8,924.16
| Facility | | $2,974.72 | $4,062.89 | $8,924.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,914.22 / $5,660.72 / $7,619.93
| Professional | | $2,914.22 | $5,660.72 | $7,619.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,316.09 / $6,029.26 / $7,619.93
| Professional | | $3,316.09 | $6,029.26 | $7,619.93 |