- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,006.36 / $3,006.36 / $8,500.00
| Facility | | $3,006.36 | $3,006.36 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,873.07 / $3,006.36 / $3,006.36
| Professional | | $2,873.07 | $3,006.36 | $3,006.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,254.15 / $6,821.17 / $8,177.09
| Professional | | $6,254.15 | $6,821.17 | $8,177.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,872.76 / $6,913.21 / $8,927.41
| Professional | | $3,872.76 | $6,913.21 | $8,927.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,006.36 / $4,269.00 / $9,019.08
| Facility | | $3,006.36 | $4,269.00 | $9,019.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,331.43 / $5,747.79 / $7,658.12
| Professional | | $3,331.43 | $5,747.79 | $7,658.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,331.43 / $6,026.19 / $7,658.12
| Professional | | $3,331.43 | $6,026.19 | $7,658.12 |