- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,953.40 / $1,953.40 / $9,500.00
| Facility | | $1,953.40 | $1,953.40 | $9,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,697.06 / $1,912.28 / $2,300.38
| Professional | | $1,697.06 | $1,912.28 | $2,300.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,159.50 / $4,575.66 / $5,365.20
| Professional | | $4,159.50 | $4,575.66 | $5,365.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,337.56 / $4,670.14 / $6,220.64
| Professional | | $2,337.56 | $4,670.14 | $6,220.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,953.40 / $2,786.27 / $3,343.52
| Facility | | $1,953.40 | $2,786.27 | $3,343.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,155.98 / $3,583.51 / $4,982.63
| Professional | | $2,155.98 | $3,583.51 | $4,982.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,155.98 / $3,583.51 / $4,743.18
| Professional | | $2,155.98 | $3,583.51 | $4,743.18 |