- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,285.03 / $1,285.03 / $8,500.00
| Facility | | $1,285.03 | $1,285.03 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,141.32 / $1,221.08 / $1,285.03
| Professional | | $1,141.32 | $1,221.08 | $1,285.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,407.19 / $2,648.04 / $3,104.97
| Professional | | $2,407.19 | $2,648.04 | $3,104.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,495.30 / $2,987.41 / $3,979.23
| Professional | | $1,495.30 | $2,987.41 | $3,979.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,285.03 / $1,699.94 / $2,184.55
| Facility | | $1,285.03 | $1,699.94 | $2,184.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,326.29 / $2,364.61 / $3,339.29
| Professional | | $1,326.29 | $2,364.61 | $3,339.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,326.29 / $2,364.61 / $3,292.86
| Professional | | $1,326.29 | $2,364.61 | $3,292.86 |