- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,216.87 / $2,216.87 / $8,500.00
| Facility | | $2,216.87 | $2,216.87 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,078.51 / $2,216.87 / $2,590.61
| Professional | | $2,078.51 | $2,216.87 | $2,590.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,723.66 / $5,196.26 / $6,092.89
| Professional | | $4,723.66 | $5,196.26 | $6,092.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,648.45 / $5,291.25 / $7,047.96
| Professional | | $2,648.45 | $5,291.25 | $7,047.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,216.87 / $2,803.64 / $3,791.61
| Facility | | $2,216.87 | $2,803.64 | $3,791.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,450.12 / $4,193.84 / $5,651.85
| Professional | | $2,450.12 | $4,193.84 | $5,651.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,450.12 / $4,336.71 / $4,784.67
| Professional | | $2,450.12 | $4,336.71 | $4,784.67 |