- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,898.81 / $2,898.81 / $8,500.00
| Facility | | $2,898.81 | $2,898.81 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,758.94 / $2,898.81 / $2,898.81
| Professional | | $2,758.94 | $2,898.81 | $2,898.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,018.03 / $6,566.81 / $7,872.17
| Professional | | $6,018.03 | $6,566.81 | $7,872.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,730.51 / $6,629.76 / $8,561.37
| Professional | | $3,730.51 | $6,629.76 | $8,561.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,898.81 / $4,099.60 / $8,696.43
| Facility | | $2,898.81 | $4,099.60 | $8,696.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,217.75 / $5,503.31 / $7,379.54
| Professional | | $3,217.75 | $5,503.31 | $7,379.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,223.88 / $5,861.60 / $7,379.54
| Professional | | $3,223.88 | $5,861.60 | $7,379.54 |