- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,106.94 / $2,106.94 / $8,500.00
| Facility | | $2,106.94 | $2,106.94 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,996.32 / $2,106.94 / $3,165.88
| Professional | | $1,996.32 | $2,106.94 | $3,165.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,118.82 / $4,483.85 / $5,297.71
| Professional | | $4,118.82 | $4,483.85 | $5,297.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,598.00 / $3,751.09 / $6,054.98
| Professional | | $2,598.00 | $3,751.09 | $6,054.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,106.94 / $2,804.76 / $6,320.82
| Facility | | $2,106.94 | $2,804.76 | $6,320.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,154.63 / $4,246.02 / $5,395.37
| Professional | | $2,154.63 | $4,246.02 | $5,395.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,487.35 / $4,522.46 / $5,395.37
| Professional | | $2,487.35 | $4,522.46 | $5,395.37 |