- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,797.12 / $3,797.12 / $8,500.00
| Facility | | $3,797.12 | $3,797.12 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,598.93 / $3,797.12 / $3,797.12
| Professional | | $3,598.93 | $3,797.12 | $3,797.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,861.92 / $8,575.61 / $10,280.28
| Professional | | $7,861.92 | $8,575.61 | $10,280.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,873.22 / $8,647.44 / $11,166.91
| Professional | | $4,873.22 | $8,647.44 | $11,166.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,797.12 / $5,350.50 / $11,391.36
| Facility | | $3,797.12 | $5,350.50 | $11,391.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,226.09 / $7,222.58 / $9,658.40
| Professional | | $4,226.09 | $7,222.58 | $9,658.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,231.04 / $7,692.80 / $9,658.40
| Professional | | $4,231.04 | $7,692.80 | $9,658.40 |