- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,711.10 / $2,711.10 / $6,971.40
| Facility | | $2,711.10 | $2,711.10 | $6,971.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,711.10 / $3,640.62 / $3,873.00
| Professional | | $2,711.10 | $3,640.62 | $3,873.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,829.83 / $7,804.10 / $8,714.25
| Professional | | $5,829.83 | $7,804.10 | $8,714.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,450.49 / $4,450.49 / $6,533.52
| Professional | | $4,450.49 | $4,450.49 | $6,533.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,323.80 / $2,850.00 / $6,971.40
| Facility | | $2,323.80 | $2,850.00 | $6,971.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,756.11 / $4,304.20 / $7,746.00
| Professional | | $1,756.11 | $4,304.20 | $7,746.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,626.66 / $3,950.46 / $6,584.10
| Professional | | $1,626.66 | $3,950.46 | $6,584.10 |