- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,456.17 / $2,456.17 / $9,500.00
| Facility | | $2,456.17 | $2,456.17 | $9,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,406.19 / $2,419.89 / $2,544.14
| Professional | | $2,406.19 | $2,419.89 | $2,544.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,909.72 / $5,400.95 / $6,332.91
| Professional | | $4,909.72 | $5,400.95 | $6,332.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,944.97 / $5,883.67 / $7,837.06
| Professional | | $2,944.97 | $5,883.67 | $7,837.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,456.17 / $3,019.14 / $4,175.51
| Facility | | $2,456.17 | $3,019.14 | $4,175.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,601.34 / $4,695.35 / $6,336.57
| Professional | | $2,601.34 | $4,695.35 | $6,336.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,601.34 / $4,604.37 / $6,336.57
| Professional | | $2,601.34 | $4,604.37 | $6,336.57 |