- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,391.68 / $1,391.68 / $8,500.00
| Facility | | $1,391.68 | $1,391.68 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,171.19 / $1,342.40 / $1,391.68
| Professional | | $1,171.19 | $1,342.40 | $1,391.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,697.77 / $2,973.53 / $3,486.62
| Professional | | $2,697.77 | $2,973.53 | $3,486.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,695.09 / $3,386.57 / $4,510.92
| Professional | | $1,695.09 | $3,386.57 | $4,510.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,391.68 / $1,946.13 / $2,652.99
| Facility | | $1,391.68 | $1,946.13 | $2,652.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,426.62 / $2,586.33 / $3,624.67
| Professional | | $1,426.62 | $2,586.33 | $3,624.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,426.62 / $2,553.04 / $3,003.66
| Professional | | $1,426.62 | $2,553.04 | $3,003.66 |