- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,359.11 / $2,359.11 / $8,500.00
| Facility | | $2,359.11 | $2,359.11 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,173.30 / $2,291.12 / $2,757.93
| Professional | | $2,173.30 | $2,291.12 | $2,757.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,963.16 / $5,506.25 / $6,477.94
| Professional | | $4,963.16 | $5,506.25 | $6,477.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,812.76 / $5,619.53 / $7,485.23
| Professional | | $2,812.76 | $5,619.53 | $7,485.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,359.11 / $2,964.59 / $4,028.38
| Facility | | $2,359.11 | $2,964.59 | $4,028.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,609.28 / $4,344.04 / $6,012.93
| Professional | | $2,609.28 | $4,344.04 | $6,012.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,609.28 / $4,344.04 / $5,829.80
| Professional | | $2,609.28 | $4,344.04 | $5,829.80 |