- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,155.19 / $2,155.19 / $8,500.00
| Facility | | $2,155.19 | $2,155.19 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,025.02 / $2,152.62 / $2,184.52
| Professional | | $2,025.02 | $2,152.62 | $2,184.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,247.14 / $4,681.26 / $5,489.03
| Professional | | $4,247.14 | $4,681.26 | $5,489.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,623.45 / $5,212.77 / $6,943.42
| Professional | | $2,623.45 | $5,212.77 | $6,943.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,155.19 / $3,272.51 / $3,663.82
| Facility | | $2,155.19 | $3,272.51 | $3,663.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,295.59 / $3,953.70 / $5,584.91
| Professional | | $2,295.59 | $3,953.70 | $5,584.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,244.77 / $3,953.70 / $5,304.57
| Professional | | $2,244.77 | $3,953.70 | $5,304.57 |