- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,489.37 / $2,489.37 / $8,500.00
| Facility | | $2,489.37 | $2,489.37 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,489.37 / $2,489.37 / $2,769.18
| Professional | | $2,489.37 | $2,489.37 | $2,769.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,156.26 / $3,156.26 / $3,156.26
| Professional | | $3,156.26 | $3,156.26 | $3,156.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,489.37 / $3,654.20 / $7,468.11
| Facility | | $2,489.37 | $3,654.20 | $7,468.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,354.98 / $4,481.49 / $6,437.38
| Professional | | $2,354.98 | $4,481.49 | $6,437.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,622.63 / $4,576.35 / $6,437.38
| Professional | | $2,622.63 | $4,576.35 | $6,437.38 |