- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,025.39 / $2,025.39 / $8,500.00
| Facility | | $2,025.39 | $2,025.39 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,936.68 / $2,025.39 / $2,025.39
| Professional | | $1,936.68 | $2,025.39 | $2,025.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,217.89 / $4,598.88 / $5,513.05
| Professional | | $4,217.89 | $4,598.88 | $5,513.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,610.46 / $4,661.91 / $6,020.17
| Professional | | $2,610.46 | $4,661.91 | $6,020.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,025.39 / $2,878.88 / $6,076.17
| Facility | | $2,025.39 | $2,878.88 | $6,076.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,240.80 / $3,836.90 / $5,161.71
| Professional | | $2,240.80 | $3,836.90 | $5,161.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,240.80 / $4,086.70 / $5,161.71
| Professional | | $2,240.80 | $4,086.70 | $5,161.71 |