- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,412.35 / $2,412.35 / $8,500.00
| Facility | | $2,412.35 | $2,412.35 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,305.89 / $2,412.35 / $2,412.35
| Professional | | $2,305.89 | $2,412.35 | $2,412.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,015.67 / $5,470.47 / $6,557.89
| Professional | | $5,015.67 | $5,470.47 | $6,557.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,104.66 / $5,550.67 / $7,167.88
| Professional | | $3,104.66 | $5,550.67 | $7,167.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,412.35 / $3,426.15 / $7,237.05
| Facility | | $2,412.35 | $3,426.15 | $7,237.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,467.67 / $4,425.46 / $6,148.48
| Professional | | $2,467.67 | $4,425.46 | $6,148.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,668.47 / $5,203.43 / $6,148.48
| Professional | | $2,668.47 | $5,203.43 | $6,148.48 |