- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,143.46 / $1,143.46 / $8,500.00
| Facility | | $1,143.46 | $1,143.46 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,073.86 / $1,143.46 / $1,143.46
| Professional | | $1,073.86 | $1,143.46 | $1,143.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,191.94 / $2,387.17 / $2,861.68
| Professional | | $2,191.94 | $2,387.17 | $2,861.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,376.50 / $2,661.38 / $3,436.78
| Professional | | $1,376.50 | $2,661.38 | $3,436.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,143.46 / $1,594.25 / $3,430.38
| Facility | | $1,143.46 | $1,594.25 | $3,430.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,188.07 / $2,151.94 / $2,962.57
| Professional | | $1,188.07 | $2,151.94 | $2,962.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,188.07 / $2,292.04 / $2,962.57
| Professional | | $1,188.07 | $2,292.04 | $2,962.57 |