- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,155.32 / $2,155.32 / $8,500.00
| Facility | | $2,155.32 | $2,155.32 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,155.32 / $2,155.32 / $2,265.58
| Professional | | $2,155.32 | $2,155.32 | $2,265.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,283.02 / $4,634.00 / $5,475.10
| Professional | | $4,283.02 | $4,634.00 | $5,475.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,677.24 / $3,923.61 / $6,333.47
| Professional | | $2,677.24 | $3,923.61 | $6,333.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,155.32 / $2,278.03 / $6,465.96
| Facility | | $2,155.32 | $2,278.03 | $6,465.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,264.93 / $4,039.45 / $5,526.46
| Professional | | $1,264.93 | $4,039.45 | $5,526.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,366.34 / $4,302.43 / $5,526.46
| Professional | | $2,366.34 | $4,302.43 | $5,526.46 |