- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,213.96 / $2,213.96 / $8,500.00
| Facility | | $2,213.96 | $2,213.96 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,001.22 / $2,178.83 / $2,247.73
| Professional | | $2,001.22 | $2,178.83 | $2,247.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,367.93 / $4,804.95 / $5,634.06
| Professional | | $4,367.93 | $4,804.95 | $5,634.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,652.67 / $5,299.69 / $7,059.20
| Professional | | $2,652.67 | $5,299.69 | $7,059.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,213.96 / $2,981.48 / $3,763.75
| Facility | | $2,213.96 | $2,981.48 | $3,763.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,323.81 / $4,061.53 / $5,728.12
| Professional | | $2,323.81 | $4,061.53 | $5,728.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,667.00 / $8,667.00 / $8,667.00
| Facility | | $8,667.00 | $8,667.00 | $8,667.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,323.81 / $4,061.53 / $5,112.38
| Professional | | $2,323.81 | $4,061.53 | $5,112.38 |