- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,109.08 / $2,109.08 / $8,500.00
| Facility | | $2,109.08 | $2,109.08 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,016.48 / $2,109.08 / $2,195.75
| Professional | | $2,016.48 | $2,109.08 | $2,195.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,143.91 / $4,505.60 / $5,323.41
| Professional | | $4,143.91 | $4,505.60 | $5,323.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,606.71 / $3,792.91 / $6,122.49
| Professional | | $2,606.71 | $3,792.91 | $6,122.49 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,109.08 / $2,752.99 / $6,327.24
| Facility | | $2,109.08 | $2,752.99 | $6,327.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,978.36 / $3,994.07 / $5,406.06
| Professional | | $1,978.36 | $3,994.07 | $5,406.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,339.76 / $3,997.54 / $5,406.06
| Professional | | $2,339.76 | $3,997.54 | $5,406.06 |