- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,274.86 / $2,274.86 / $8,500.00
| Facility | | $2,274.86 | $2,274.86 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,149.09 / $2,274.86 / $3,448.52
| Professional | | $2,149.09 | $2,274.86 | $3,448.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,463.66 / $4,857.81 / $5,739.54
| Professional | | $4,463.66 | $4,857.81 | $5,739.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,063.86 / $4,082.41 / $6,589.80
| Professional | | $3,063.86 | $4,082.41 | $6,589.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,274.86 / $3,121.41 / $6,824.58
| Facility | | $2,274.86 | $3,121.41 | $6,824.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,373.46 / $4,308.25 / $5,829.91
| Professional | | $2,373.46 | $4,308.25 | $5,829.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,523.81 / $4,588.74 / $5,829.91
| Professional | | $2,523.81 | $4,588.74 | $5,829.91 |