- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,630.13 / $2,630.13 / $8,500.00
| Facility | | $2,630.13 | $2,630.13 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,400.87 / $2,630.13 / $3,956.01
| Professional | | $2,400.87 | $2,630.13 | $3,956.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,339.10 / $5,873.28 / $6,886.73
| Professional | | $5,339.10 | $5,873.28 | $6,886.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,917.47 / $5,183.85 / $7,769.15
| Professional | | $2,917.47 | $5,183.85 | $7,769.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,475.69 / $3,320.26 / $5,418.23
| Facility | | $2,475.69 | $3,320.26 | $5,418.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,448.01 / $4,732.70 / $19,403.20
| Professional | | $2,448.01 | $4,732.70 | $19,403.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $681.00 / $681.00 / $681.00
| Facility | | $681.00 | $681.00 | $681.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,470.56 / $4,972.74 / $6,746.30
| Professional | | $2,470.56 | $4,972.74 | $6,746.30 |