- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,464.07 / $2,464.07 / $8,500.00
| Facility | | $2,464.07 | $2,464.07 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,464.07 / $2,464.07 / $2,534.67
| Professional | | $2,464.07 | $2,464.07 | $2,534.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,820.82 / $5,233.85 / $6,183.84
| Professional | | $4,820.82 | $5,233.85 | $6,183.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,360.82 / $4,354.27 / $7,028.63
| Professional | | $3,360.82 | $4,354.27 | $7,028.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,464.07 / $3,018.28 / $7,392.21
| Facility | | $2,464.07 | $3,018.28 | $7,392.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,672.80 / $4,628.00 / $6,303.50
| Professional | | $2,672.80 | $4,628.00 | $6,303.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,937.69 / $5,318.20 / $6,303.50
| Professional | | $2,937.69 | $5,318.20 | $6,303.50 |