- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,113.71 / $2,113.71 / $8,500.00
| Facility | | $2,113.71 | $2,113.71 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,076.61 / $2,113.71 / $2,113.71
| Professional | | $2,076.61 | $2,113.71 | $2,113.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,097.60 / $4,498.13 / $5,392.26
| Professional | | $4,097.60 | $4,498.13 | $5,392.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,614.04 / $4,990.29 / $6,444.23
| Professional | | $2,614.04 | $4,990.29 | $6,444.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,113.71 / $2,738.37 / $6,341.16
| Facility | | $2,113.71 | $2,738.37 | $6,341.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,196.05 / $3,995.80 / $5,483.58
| Professional | | $2,196.05 | $3,995.80 | $5,483.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,196.05 / $4,255.93 / $5,483.58
| Professional | | $2,196.05 | $4,255.93 | $5,483.58 |