- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,431.15 / $2,431.15 / $8,500.00
| Facility | | $2,431.15 | $2,431.15 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,323.17 / $2,431.15 / $3,748.32
| Professional | | $2,323.17 | $2,431.15 | $3,748.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,060.07 / $5,518.38 / $6,615.32
| Professional | | $5,060.07 | $5,518.38 | $6,615.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,133.51 / $5,589.06 / $7,217.45
| Professional | | $3,133.51 | $5,589.06 | $7,217.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,431.15 / $3,452.13 / $7,293.45
| Facility | | $2,431.15 | $3,452.13 | $7,293.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,692.28 / $4,619.83 / $6,193.86
| Professional | | $2,692.28 | $4,619.83 | $6,193.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,706.33 / $4,875.24 / $6,193.86
| Professional | | $2,706.33 | $4,875.24 | $6,193.86 |