- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,587.64 / $2,587.64 / $8,500.00
| Facility | | $2,587.64 | $2,587.64 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,431.31 / $2,566.84 / $3,026.33
| Professional | | $2,431.31 | $2,566.84 | $3,026.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,502.83 / $6,053.38 / $7,097.91
| Professional | | $5,502.83 | $6,053.38 | $7,097.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,076.34 / $6,146.12 / $8,186.65
| Professional | | $3,076.34 | $6,146.12 | $8,186.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,587.64 / $3,490.53 / $4,632.53
| Facility | | $2,587.64 | $3,490.53 | $4,632.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,865.88 / $4,954.71 / $6,592.45
| Professional | | $2,865.88 | $4,954.71 | $6,592.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,987.70 / $5,987.70 / $5,987.70
| Facility | | $5,987.70 | $5,987.70 | $5,987.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,865.88 / $4,747.03 / $6,304.94
| Professional | | $2,865.88 | $4,747.03 | $6,304.94 |