- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,152.59 / $1,152.59 / $8,500.00
| Facility | | $1,152.59 | $1,152.59 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,027.55 / $1,152.59 / $1,743.40
| Professional | | $1,027.55 | $1,152.59 | $1,743.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,231.84 / $2,448.46 / $2,935.18
| Professional | | $2,231.84 | $2,448.46 | $2,935.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,418.10 / $2,660.56 / $3,435.73
| Professional | | $1,418.10 | $2,660.56 | $3,435.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,152.59 / $1,603.01 / $3,457.80
| Facility | | $1,152.59 | $1,603.01 | $3,457.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,250.83 / $2,135.23 / $2,977.42
| Professional | | $1,250.83 | $2,135.23 | $2,977.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,211.89 / $2,274.23 / $2,977.42
| Professional | | $1,211.89 | $2,274.23 | $2,977.42 |