- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,653.58 / $2,653.58 / $8,500.00
| Facility | | $2,653.58 | $2,653.58 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,653.58 / $2,653.58 / $2,775.56
| Professional | | $2,653.58 | $2,653.58 | $2,775.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,224.13 / $5,684.28 / $6,716.02
| Professional | | $5,224.13 | $5,684.28 | $6,716.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,573.37 / $4,794.72 / $7,739.62
| Professional | | $3,573.37 | $4,794.72 | $7,739.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,653.58 / $3,660.47 / $7,960.74
| Facility | | $2,653.58 | $3,660.47 | $7,960.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,731.98 / $5,002.51 / $6,804.43
| Professional | | $2,731.98 | $5,002.51 | $6,804.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,930.51 / $5,064.29 / $6,804.43
| Professional | | $2,930.51 | $5,064.29 | $6,804.43 |