- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,453.44 / $2,453.44 / $8,500.00
| Facility | | $2,453.44 | $2,453.44 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,344.48 / $2,453.44 / $2,453.44
| Professional | | $2,344.48 | $2,453.44 | $2,453.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,107.03 / $5,569.10 / $6,676.14
| Professional | | $5,107.03 | $5,569.10 | $6,676.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,162.55 / $5,639.71 / $7,282.86
| Professional | | $3,162.55 | $5,639.71 | $7,282.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,453.44 / $3,483.80 / $7,360.35
| Facility | | $2,453.44 | $3,483.80 | $7,360.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,717.19 / $4,697.38 / $6,250.50
| Professional | | $2,717.19 | $4,697.38 | $6,250.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,001.92 / $5,571.72 / $6,421.80
| Professional | | $3,001.92 | $5,571.72 | $6,421.80 |