- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,007.14 / $2,007.14 / $8,500.00
| Facility | | $2,007.14 | $2,007.14 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,923.61 / $2,007.14 / $2,007.14
| Professional | | $1,923.61 | $2,007.14 | $2,007.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,178.66 / $4,557.31 / $5,463.22
| Professional | | $4,178.66 | $4,557.31 | $5,463.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,586.42 / $4,632.50 / $5,982.20
| Professional | | $2,586.42 | $4,632.50 | $5,982.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,007.14 / $2,857.02 / $6,021.42
| Facility | | $2,007.14 | $2,857.02 | $6,021.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,217.35 / $3,813.15 / $5,117.93
| Professional | | $2,217.35 | $3,813.15 | $5,117.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,233.77 / $4,329.58 / $5,117.93
| Professional | | $2,233.77 | $4,329.58 | $5,117.93 |