- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,034.48 / $2,034.48 / $8,500.00
| Facility | | $2,034.48 | $2,034.48 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,034.48 / $2,034.48 / $2,110.57
| Professional | | $2,034.48 | $2,034.48 | $2,110.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,000.89 / $4,337.22 / $5,124.47
| Professional | | $4,000.89 | $4,337.22 | $5,124.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,801.95 / $3,641.96 / $5,878.82
| Professional | | $2,801.95 | $3,641.96 | $5,878.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,034.48 / $2,786.25 / $6,103.44
| Facility | | $2,034.48 | $2,786.25 | $6,103.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,197.86 / $4,086.00 / $5,212.88
| Professional | | $2,197.86 | $4,086.00 | $5,212.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,393.61 / $4,352.02 / $5,212.88
| Professional | | $2,393.61 | $4,352.02 | $5,212.88 |