- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,038.16 / $2,038.16 / $8,500.00
| Facility | | $2,038.16 | $2,038.16 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,887.03 / $2,011.02 / $2,068.55
| Professional | | $1,887.03 | $2,011.02 | $2,068.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,045.75 / $4,450.52 / $5,218.47
| Professional | | $4,045.75 | $4,450.52 | $5,218.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,461.75 / $4,918.25 / $6,551.12
| Professional | | $2,461.75 | $4,918.25 | $6,551.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,038.16 / $2,487.85 / $3,464.87
| Facility | | $2,038.16 | $2,487.85 | $3,464.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,137.23 / $3,739.00 / $5,275.34
| Professional | | $2,137.23 | $3,739.00 | $5,275.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,978.00 / $1,978.00 / $1,978.00
| Facility | | $1,978.00 | $1,978.00 | $1,978.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,137.23 / $3,755.87 / $5,275.34
| Professional | | $2,137.23 | $3,755.87 | $5,275.34 |