- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,987.86 / $1,987.86 / $9,500.00
| Facility | | $1,987.86 | $1,987.86 | $9,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,693.45 / $1,956.10 / $2,062.50
| Professional | | $1,693.45 | $1,956.10 | $2,062.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,982.02 / $4,389.04 / $5,146.39
| Professional | | $3,982.02 | $4,389.04 | $5,146.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,396.69 / $4,788.29 / $6,378.01
| Professional | | $2,396.69 | $4,788.29 | $6,378.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,987.86 / $2,777.89 / $3,379.36
| Facility | | $1,987.86 | $2,777.89 | $3,379.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,147.33 / $3,709.08 / $5,100.37
| Professional | | $2,147.33 | $3,709.08 | $5,100.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,147.33 / $3,646.73 / $4,724.13
| Professional | | $2,147.33 | $3,646.73 | $4,724.13 |