- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,236.71 / $2,236.71 / $8,500.00
| Facility | | $2,236.71 | $2,236.71 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,236.71 / $2,236.71 / $2,312.04
| Professional | | $2,236.71 | $2,236.71 | $2,312.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,371.02 / $4,758.89 / $5,622.66
| Professional | | $4,371.02 | $4,758.89 | $5,622.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,757.87 / $3,979.16 / $6,423.13
| Professional | | $2,757.87 | $3,979.16 | $6,423.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,236.71 / $3,048.72 / $6,710.16
| Facility | | $2,236.71 | $3,048.72 | $6,710.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,236.59 / $4,508.05 / $5,727.39
| Professional | | $2,236.59 | $4,508.05 | $5,727.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,640.85 / $4,827.51 / $5,727.39
| Professional | | $2,640.85 | $4,827.51 | $5,727.39 |