- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,321.09 / $3,321.09 / $8,500.00
| Facility | | $3,321.09 | $3,321.09 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,321.09 / $3,340.21 / $4,991.60
| Professional | | $3,321.09 | $3,340.21 | $4,991.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,492.84 / $7,065.01 / $8,347.36
| Professional | | $6,492.84 | $7,065.01 | $8,347.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,564.32 / $5,913.52 / $9,545.56
| Professional | | $4,564.32 | $5,913.52 | $9,545.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,321.09 / $4,529.63 / $9,963.27
| Facility | | $3,321.09 | $4,529.63 | $9,963.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,704.38 / $6,690.59 / $8,502.77
| Professional | | $3,704.38 | $6,690.59 | $8,502.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,264.68 / $7,126.18 / $8,502.77
| Professional | | $4,264.68 | $7,126.18 | $8,502.77 |