- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,496.86 / $2,496.86 / $8,500.00
| Facility | | $2,496.86 | $2,496.86 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,162.54 / $2,443.15 / $2,585.57
| Professional | | $2,162.54 | $2,443.15 | $2,585.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,878.63 / $5,466.59 / $6,431.29
| Professional | | $4,878.63 | $5,466.59 | $6,431.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,761.00 / $5,972.28 / $7,955.09
| Professional | | $2,761.00 | $5,972.28 | $7,955.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,058.51 / $2,496.86 / $4,184.22
| Facility | | $2,058.51 | $2,496.86 | $4,184.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,645.37 / $4,637.12 / $6,440.71
| Professional | | $2,645.37 | $4,637.12 | $6,440.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,645.37 / $4,580.49 / $5,819.81
| Professional | | $2,645.37 | $4,580.49 | $5,819.81 |