- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,859.32 / $2,859.32 / $8,500.00
| Facility | | $2,859.32 | $2,859.32 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,688.50 / $2,835.84 / $3,344.80
| Professional | | $2,688.50 | $2,835.84 | $3,344.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,072.24 / $6,679.76 / $7,832.39
| Professional | | $6,072.24 | $6,679.76 | $7,832.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,389.34 / $6,771.45 / $9,019.59
| Professional | | $3,389.34 | $6,771.45 | $9,019.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,859.32 / $3,734.00 / $5,115.82
| Facility | | $2,859.32 | $3,734.00 | $5,115.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,171.19 / $5,455.00 / $7,281.19
| Professional | | $3,171.19 | $5,455.00 | $7,281.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,171.19 / $5,229.13 / $6,976.62
| Professional | | $3,171.19 | $5,229.13 | $6,976.62 |