- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,157.53 / $1,157.53 / $8,500.00
| Facility | | $1,157.53 | $1,157.53 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,086.70 / $1,157.53 / $1,157.53
| Professional | | $1,086.70 | $1,157.53 | $1,157.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,218.96 / $2,415.34 / $2,895.47
| Professional | | $2,218.96 | $2,415.34 | $2,895.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,392.91 / $2,693.24 / $3,477.92
| Professional | | $1,392.91 | $2,693.24 | $3,477.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,157.53 / $1,604.98 / $3,472.59
| Facility | | $1,157.53 | $1,604.98 | $3,472.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.51 / $2,175.66 / $2,999.16
| Professional | | $1,202.51 | $2,175.66 | $2,999.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,753.00 / $5,753.00 / $5,753.00
| Facility | | $5,753.00 | $5,753.00 | $5,753.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,274.52 / $2,175.66 / $2,999.16
| Professional | | $1,274.52 | $2,175.66 | $2,999.16 |