- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,059.12 / $2,059.12 / $8,500.00
| Facility | | $2,059.12 | $2,059.12 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,973.62 / $2,059.12 / $2,059.12
| Professional | | $1,973.62 | $2,059.12 | $2,059.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,293.82 / $4,680.60 / $5,611.03
| Professional | | $4,293.82 | $4,680.60 | $5,611.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,653.44 / $4,759.10 / $6,145.70
| Professional | | $2,653.44 | $4,759.10 | $6,145.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,059.12 / $2,935.67 / $6,177.36
| Facility | | $2,059.12 | $2,935.67 | $6,177.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,275.09 / $3,929.76 / $5,250.26
| Professional | | $2,275.09 | $3,929.76 | $5,250.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,275.09 / $4,185.60 / $5,250.26
| Professional | | $2,275.09 | $4,185.60 | $5,250.26 |