- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,187.73 / $2,187.73 / $9,500.00
| Facility | | $2,187.73 | $2,187.73 | $9,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,789.09 / $2,136.76 / $2,581.01
| Professional | | $1,789.09 | $2,136.76 | $2,581.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,656.59 / $5,122.47 / $6,006.38
| Professional | | $4,656.59 | $5,122.47 | $6,006.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,610.42 / $5,215.30 / $6,946.80
| Professional | | $2,610.42 | $5,215.30 | $6,946.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,187.73 / $3,114.41 / $3,737.29
| Facility | | $2,187.73 | $3,114.41 | $3,737.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,292.00 / $3,595.85 / $5,577.82
| Professional | | $2,292.00 | $3,595.85 | $5,577.82 |
- 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
- $2,297.98 / $3,829.96 / $5,318.81
| Professional | | $2,297.98 | $3,829.96 | $5,318.81 |