- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,318.46 / $2,318.46 / $8,500.00
| Facility | | $2,318.46 | $2,318.46 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,010.18 / $2,221.07 / $2,710.28
| Professional | | $2,010.18 | $2,221.07 | $2,710.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,937.35 / $5,431.33 / $6,368.53
| Professional | | $4,937.35 | $5,431.33 | $6,368.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,765.45 / $5,525.01 / $7,359.33
| Professional | | $2,765.45 | $5,525.01 | $7,359.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,318.46 / $2,840.78 / $3,960.59
| Facility | | $2,318.46 | $2,840.78 | $3,960.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,428.48 / $4,047.48 / $5,909.49
| Professional | | $2,428.48 | $4,047.48 | $5,909.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,428.48 / $4,047.48 / $5,641.17
| Professional | | $2,428.48 | $4,047.48 | $5,641.17 |