- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,652.21 / $2,652.21 / $8,500.00
| Facility | | $2,652.21 | $2,652.21 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,652.21 / $2,652.21 / $2,754.11
| Professional | | $2,652.21 | $2,652.21 | $2,754.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,188.09 / $5,650.60 / $6,676.23
| Professional | | $5,188.09 | $5,650.60 | $6,676.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,270.85 / $4,747.68 / $7,663.67
| Professional | | $3,270.85 | $4,747.68 | $7,663.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,652.21 / $3,630.00 / $7,956.63
| Facility | | $2,652.21 | $3,630.00 | $7,956.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,982.33 / $5,011.47 / $6,792.07
| Professional | | $1,982.33 | $5,011.47 | $6,792.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,935.76 / $5,337.74 / $6,792.07
| Professional | | $2,935.76 | $5,337.74 | $6,792.07 |