- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,095.04 / $2,095.04 / $8,500.00
| Facility | | $2,095.04 | $2,095.04 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,043.79 / $2,095.04 / $3,182.62
| Professional | | $2,043.79 | $2,095.04 | $3,182.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,113.68 / $4,475.45 / $5,287.77
| Professional | | $4,113.68 | $4,475.45 | $5,287.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,907.36 / $3,766.77 / $6,080.30
| Professional | | $2,907.36 | $3,766.77 | $6,080.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,095.04 / $2,878.79 / $6,285.12
| Facility | | $2,095.04 | $2,878.79 | $6,285.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,186.46 / $3,967.54 / $5,370.11
| Professional | | $2,186.46 | $3,967.54 | $5,370.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,324.21 / $4,225.84 / $5,370.11
| Professional | | $2,324.21 | $4,225.84 | $5,370.11 |