- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,133.38 / $2,133.38 / $9,500.00
| Facility | | $2,133.38 | $2,133.38 | $9,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,846.53 / $2,094.15 / $2,510.71
| Professional | | $1,846.53 | $2,094.15 | $2,510.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,549.42 / $5,004.58 / $5,868.13
| Professional | | $4,549.42 | $5,004.58 | $5,868.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,562.28 / $5,119.10 / $6,818.65
| Professional | | $2,562.28 | $5,119.10 | $6,818.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,133.38 / $2,797.56 / $3,661.22
| Facility | | $2,133.38 | $2,797.56 | $3,661.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,181.21 / $3,723.43 / $5,443.65
| Professional | | $2,181.21 | $3,723.43 | $5,443.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,352.32 / $3,913.69 / $4,604.47
| Professional | | $2,352.32 | $3,913.69 | $4,604.47 |