- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,028.17 / $2,028.17 / $8,500.00
| Facility | | $2,028.17 | $2,028.17 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,946.97 / $2,028.17 / $3,153.12
| Professional | | $1,946.97 | $2,028.17 | $3,153.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,230.76 / $4,612.27 / $5,529.10
| Professional | | $4,230.76 | $4,612.27 | $5,529.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,618.61 / $4,688.05 / $6,053.93
| Professional | | $2,618.61 | $4,688.05 | $6,053.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,028.17 / $2,892.09 / $6,084.51
| Facility | | $2,028.17 | $2,892.09 | $6,084.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,241.16 / $3,881.03 / $5,171.07
| Professional | | $2,241.16 | $3,881.03 | $5,171.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,273.54 / $4,074.73 / $5,171.07
| Professional | | $2,273.54 | $4,074.73 | $5,171.07 |