- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,180.10 / $2,180.10 / $9,500.00
| Facility | | $2,180.10 | $2,180.10 | $9,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,858.26 / $2,145.13 / $2,258.79
| Professional | | $1,858.26 | $2,145.13 | $2,258.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,372.54 / $4,810.01 / $5,640.00
| Professional | | $4,372.54 | $4,810.01 | $5,640.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,628.60 / $5,251.59 / $6,995.13
| Professional | | $2,628.60 | $5,251.59 | $6,995.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,180.10 / $2,991.81 / $3,706.17
| Facility | | $2,180.10 | $2,991.81 | $3,706.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,306.48 / $4,065.02 / $5,626.80
| Professional | | $2,306.48 | $4,065.02 | $5,626.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,306.48 / $3,999.39 / $5,074.28
| Professional | | $2,306.48 | $3,999.39 | $5,074.28 |