- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,483.61 / $2,483.61 / $8,500.00
| Facility | | $2,483.61 | $2,483.61 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,269.03 / $2,431.48 / $2,518.09
| Professional | | $2,269.03 | $2,431.48 | $2,518.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,896.59 / $5,386.49 / $6,315.94
| Professional | | $4,896.59 | $5,386.49 | $6,315.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,967.78 / $5,929.24 / $7,897.77
| Professional | | $2,967.78 | $5,929.24 | $7,897.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,483.61 / $3,325.10 / $4,222.14
| Facility | | $2,483.61 | $3,325.10 | $4,222.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,610.00 / $4,618.53 / $6,422.52
| Professional | | $2,610.00 | $4,618.53 | $6,422.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,610.00 / $4,556.18 / $6,422.52
| Professional | | $2,610.00 | $4,556.18 | $6,422.52 |