- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,455.73 / $2,455.73 / $8,500.00
| Facility | | $2,455.73 | $2,455.73 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,015.44 / $2,408.92 / $2,458.21
| Professional | | $2,015.44 | $2,408.92 | $2,458.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,804.53 / $5,285.22 / $6,197.21
| Professional | | $4,804.53 | $5,285.22 | $6,197.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,936.52 / $5,866.79 / $7,814.58
| Professional | | $2,936.52 | $5,866.79 | $7,814.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,455.73 / $2,875.68 / $4,174.74
| Facility | | $2,455.73 | $2,875.68 | $4,174.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,550.48 / $4,214.96 / $6,364.54
| Professional | | $2,550.48 | $4,214.96 | $6,364.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,566.69 / $3,793.46 / $5,611.78
| Professional | | $2,566.69 | $3,793.46 | $5,611.78 |