- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,860.04 / $2,860.04 / $8,500.00
| Facility | | $2,860.04 | $2,860.04 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,690.92 / $2,838.67 / $3,346.30
| Professional | | $2,690.92 | $2,838.67 | $3,346.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,072.90 / $6,680.49 / $7,833.23
| Professional | | $6,072.90 | $6,680.49 | $7,833.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,389.76 / $6,772.30 / $9,020.71
| Professional | | $3,389.76 | $6,772.30 | $9,020.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,860.04 / $3,734.40 / $4,862.07
| Facility | | $2,860.04 | $3,734.40 | $4,862.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,171.91 / $5,435.28 / $7,283.09
| Professional | | $3,171.91 | $5,435.28 | $7,283.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,171.91 / $5,246.74 / $6,978.20
| Professional | | $3,171.91 | $5,246.74 | $6,978.20 |