- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,204.04 / $2,204.04 / $8,500.00
| Facility | | $2,204.04 | $2,204.04 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,204.04 / $2,204.04 / $2,285.84
| Professional | | $2,204.04 | $2,204.04 | $2,285.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,315.70 / $4,697.85 / $5,550.55
| Professional | | $4,315.70 | $4,697.85 | $5,550.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,984.32 / $3,939.30 / $6,358.79
| Professional | | $2,984.32 | $3,939.30 | $6,358.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,204.04 / $3,014.73 / $6,612.12
| Facility | | $2,204.04 | $3,014.73 | $6,612.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,303.05 / $4,425.18 / $5,646.48
| Professional | | $2,303.05 | $4,425.18 | $5,646.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,592.30 / $4,713.28 / $5,646.48
| Professional | | $2,592.30 | $4,713.28 | $5,646.48 |