- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,090.44 / $1,090.44 / $8,500.00
| Facility | | $1,090.44 | $1,090.44 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $944.47 / $1,090.44 / $1,768.74
| Professional | | $944.47 | $1,090.44 | $1,768.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,221.12 / $2,443.34 / $2,864.94
| Professional | | $2,221.12 | $2,443.34 | $2,864.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,351.26 / $2,699.64 / $3,595.92
| Professional | | $1,351.26 | $2,699.64 | $3,595.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,090.44 / $1,395.03 / $1,879.34
| Facility | | $1,090.44 | $1,395.03 | $1,879.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,146.57 / $2,000.41 / $2,821.36
| Professional | | $1,146.57 | $2,000.41 | $2,821.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,146.57 / $1,949.92 / $2,353.50
| Professional | | $1,146.57 | $1,949.92 | $2,353.50 |