- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,290.60 / $2,290.60 / $8,500.00
| Facility | | $2,290.60 | $2,290.60 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.60 / $2,290.60 / $2,371.92
| Professional | | $2,290.60 | $2,290.60 | $2,371.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,499.95 / $4,879.56 / $5,765.24
| Professional | | $4,499.95 | $4,879.56 | $5,765.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,155.53 / $4,088.30 / $6,599.30
| Professional | | $3,155.53 | $4,088.30 | $6,599.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,290.60 / $3,130.14 / $6,871.80
| Facility | | $2,290.60 | $3,130.14 | $6,871.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,324.13 / $4,611.35 / $5,866.85
| Professional | | $2,324.13 | $4,611.35 | $5,866.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,701.37 / $4,911.58 / $5,866.85
| Professional | | $2,701.37 | $4,911.58 | $5,866.85 |