- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,057.92 / $1,057.92 / $8,500.00
| Facility | | $1,057.92 | $1,057.92 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,027.44 / $1,057.92 / $1,057.92
| Professional | | $1,027.44 | $1,057.92 | $1,057.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,078.71 / $2,284.30 / $2,738.36
| Professional | | $2,078.71 | $2,284.30 | $2,738.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,322.84 / $2,495.55 / $3,222.64
| Professional | | $1,322.84 | $2,495.55 | $3,222.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,057.92 / $1,498.77 / $3,173.76
| Facility | | $1,057.92 | $1,498.77 | $3,173.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,109.03 / $1,940.75 / $2,736.36
| Professional | | $1,109.03 | $1,940.75 | $2,736.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,109.03 / $2,060.14 / $2,736.36
| Professional | | $1,109.03 | $2,060.14 | $2,736.36 |