- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,576.48 / $2,576.48 / $8,500.00
| Facility | | $2,576.48 | $2,576.48 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,604.69 / $2,576.48 / $2,657.06
| Professional | | $1,604.69 | $2,576.48 | $2,657.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,943.62 / $5,369.27 / $6,343.83
| Professional | | $4,943.62 | $5,369.27 | $6,343.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,151.56 / $4,545.75 / $7,337.71
| Professional | | $3,151.56 | $4,545.75 | $7,337.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,576.48 / $2,927.45 / $7,729.47
| Facility | | $2,576.48 | $2,927.45 | $7,729.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,637.36 / $4,825.03 / $6,600.79
| Professional | | $1,637.36 | $4,825.03 | $6,600.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,083.50 / $5,139.16 / $6,028.72
| Professional | | $3,083.50 | $5,139.16 | $6,028.72 |