- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,700.46 / $2,700.46 / $8,500.00
| Facility | | $2,700.46 | $2,700.46 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,313.33 / $2,551.94 / $3,624.20
| Professional | | $2,313.33 | $2,551.94 | $3,624.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,228.63 / $5,655.52 / $6,766.46
| Professional | | $5,228.63 | $5,655.52 | $6,766.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,875.31 / $6,276.05 / $8,104.60
| Professional | | $3,875.31 | $6,276.05 | $8,104.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,700.46 / $3,286.00 / $4,590.78
| Facility | | $2,700.46 | $3,286.00 | $4,590.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,661.98 / $4,544.12 / $19,758.32
| Professional | | $2,661.98 | $4,544.12 | $19,758.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,313.00 / $2,313.00 / $2,313.00
| Facility | | $2,313.00 | $2,313.00 | $2,313.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,549.14 / $4,159.13 / $6,986.45
| Professional | | $2,549.14 | $4,159.13 | $6,986.45 |