- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,134.80 / $2,134.80 / $9,500.00
| Facility | | $2,134.80 | $2,134.80 | $9,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,987.43 / $2,089.00 / $2,208.98
| Professional | | $1,987.43 | $2,089.00 | $2,208.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,266.02 / $4,692.84 / $5,502.60
| Professional | | $4,266.02 | $4,692.84 | $5,502.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,558.05 / $5,110.66 / $6,807.41
| Professional | | $2,558.05 | $5,110.66 | $6,807.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,134.80 / $2,931.06 / $3,629.16
| Facility | | $2,134.80 | $2,931.06 | $3,629.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,261.37 / $3,966.49 / $5,507.07
| Professional | | $2,261.37 | $3,966.49 | $5,507.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,261.37 / $3,916.29 / $4,975.01
| Professional | | $2,261.37 | $3,916.29 | $4,975.01 |