- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,176.35 / $2,176.35 / $8,500.00
| Facility | | $2,176.35 | $2,176.35 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,085.77 / $2,176.35 / $2,176.35
| Professional | | $2,085.77 | $2,176.35 | $2,176.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,536.37 / $4,947.66 / $5,931.16
| Professional | | $4,536.37 | $4,947.66 | $5,931.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,808.87 / $5,020.51 / $6,483.26
| Professional | | $2,808.87 | $5,020.51 | $6,483.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,176.35 / $3,098.66 / $6,529.05
| Facility | | $2,176.35 | $3,098.66 | $6,529.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,406.82 / $4,148.10 / $5,547.32
| Professional | | $2,406.82 | $4,148.10 | $5,547.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,406.82 / $4,418.16 / $5,547.32
| Professional | | $2,406.82 | $4,418.16 | $5,547.32 |