- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,011.17 / $2,011.17 / $8,500.00
| Facility | | $2,011.17 | $2,011.17 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,011.17 / $2,011.17 / $2,097.67
| Professional | | $2,011.17 | $2,011.17 | $2,097.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,879.49 / $4,250.10 / $5,094.95
| Professional | | $3,879.49 | $4,250.10 | $5,094.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,468.96 / $4,722.35 / $6,098.23
| Professional | | $2,468.96 | $4,722.35 | $6,098.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,011.17 / $2,821.22 / $6,033.51
| Facility | | $2,011.17 | $2,821.22 | $6,033.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.23 / $3,830.40 / $5,217.75
| Professional | | $2,089.23 | $3,830.40 | $5,217.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,243.88 / $4,079.78 / $5,217.75
| Professional | | $2,243.88 | $4,079.78 | $5,217.75 |