- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,686.89 / $2,686.89 / $8,500.00
| Facility | | $2,686.89 | $2,686.89 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,050.59 / $2,603.13 / $2,686.89
| Professional | | $2,050.59 | $2,603.13 | $2,686.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,489.19 / $6,017.94 / $7,214.18
| Professional | | $5,489.19 | $6,017.94 | $7,214.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,435.89 / $6,199.26 / $8,005.45
| Professional | | $3,435.89 | $6,199.26 | $8,005.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,686.89 / $3,176.19 / $8,060.67
| Facility | | $2,686.89 | $3,176.19 | $8,060.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,659.35 / $4,835.18 / $6,880.15
| Professional | | $2,659.35 | $4,835.18 | $6,880.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,978.00 / $1,978.00 / $1,978.00
| Facility | | $1,978.00 | $1,978.00 | $1,978.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,659.35 / $5,193.32 / $6,880.15
| Professional | | $2,659.35 | $5,193.32 | $6,880.15 |