- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,466.63 / $2,466.63 / $8,500.00
| Facility | | $2,466.63 | $2,466.63 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,307.05 / $2,466.63 / $2,884.06
| Professional | | $2,307.05 | $2,466.63 | $2,884.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,250.33 / $5,775.63 / $6,772.23
| Professional | | $5,250.33 | $5,775.63 | $6,772.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,937.37 / $5,868.48 / $7,816.83
| Professional | | $2,937.37 | $5,868.48 | $7,816.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,466.63 / $3,415.65 / $4,409.04
| Facility | | $2,466.63 | $3,415.65 | $4,409.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,730.18 / $4,723.59 / $6,285.46
| Professional | | $2,730.18 | $4,723.59 | $6,285.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,730.18 / $4,832.42 / $6,285.46
| Professional | | $2,730.18 | $4,832.42 | $6,285.46 |