- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,445.60 / $1,445.60 / $8,500.00
| Facility | | $1,445.60 | $1,445.60 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,347.48 / $1,430.84 / $1,445.60
| Professional | | $1,347.48 | $1,430.84 | $1,445.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,785.93 / $3,064.67 / $3,593.48
| Professional | | $2,785.93 | $3,064.67 | $3,593.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,746.62 / $3,489.53 / $4,648.06
| Professional | | $1,746.62 | $3,489.53 | $4,648.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,445.60 / $1,713.15 / $2,457.52
| Facility | | $1,445.60 | $1,713.15 | $2,457.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,481.84 / $2,629.67 / $3,765.14
| Professional | | $1,481.84 | $2,629.67 | $3,765.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,481.84 / $2,622.86 / $3,260.05
| Professional | | $1,481.84 | $2,622.86 | $3,260.05 |