- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,665.57 / $2,665.57 / $8,500.00
| Facility | | $2,665.57 | $2,665.57 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,527.55 / $2,665.57 / $4,263.47
| Professional | | $2,527.55 | $2,665.57 | $4,263.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,208.68 / $5,740.33 / $6,866.37
| Professional | | $5,208.68 | $5,740.33 | $6,866.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,342.03 / $6,364.27 / $8,218.53
| Professional | | $3,342.03 | $6,364.27 | $8,218.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,665.57 / $3,279.73 / $7,996.71
| Facility | | $2,665.57 | $3,279.73 | $7,996.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,764.82 / $4,969.09 / $6,920.35
| Professional | | $2,764.82 | $4,969.09 | $6,920.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,910.93 / $5,292.60 / $6,920.35
| Professional | | $2,910.93 | $5,292.60 | $6,920.35 |