- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,185.71 / $2,185.71 / $9,500.00
| Facility | | $2,185.71 | $2,185.71 | $9,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,717.93 / $2,144.25 / $2,573.39
| Professional | | $1,717.93 | $2,144.25 | $2,573.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,574.20 / $5,107.59 / $6,008.93
| Professional | | $4,574.20 | $5,107.59 | $6,008.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,622.26 / $5,238.93 / $6,978.27
| Professional | | $2,622.26 | $5,238.93 | $6,978.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,185.71 / $2,864.69 / $3,748.03
| Facility | | $2,185.71 | $2,864.69 | $3,748.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,304.01 / $3,933.04 / $5,576.57
| Professional | | $2,304.01 | $3,933.04 | $5,576.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,410.79 / $4,009.68 / $5,303.74
| Professional | | $2,410.79 | $4,009.68 | $5,303.74 |