- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,141.54 / $1,141.54 / $8,500.00
| Facility | | $1,141.54 | $1,141.54 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,087.74 / $1,141.54 / $1,255.68
| Professional | | $1,087.74 | $1,141.54 | $1,255.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,271.08 / $2,502.71 / $2,993.86
| Professional | | $2,271.08 | $2,502.71 | $2,993.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,455.25 / $2,802.70 / $3,619.28
| Professional | | $1,455.25 | $2,802.70 | $3,619.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,141.54 / $1,321.36 / $3,424.62
| Facility | | $1,141.54 | $1,321.36 | $3,424.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,177.96 / $2,104.81 / $2,970.46
| Professional | | $1,177.96 | $2,104.81 | $2,970.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,233.01 / $2,241.84 / $2,970.46
| Professional | | $1,233.01 | $2,241.84 | $2,970.46 |