- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,286.86 / $1,400.00 / $2,300.00
| Facility | | $1,286.86 | $1,400.00 | $2,300.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,286.86 / $1,391.16 / $2,086.35
| Professional | | $1,286.86 | $1,391.16 | $2,086.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,268.75 / $1,391.49 / $1,658.79
| Facility | | $1,268.75 | $1,391.49 | $1,658.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $756.54 / $1,474.48 / $1,474.48
| Professional | | $756.54 | $1,474.48 | $1,474.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,490.92 / $1,490.92 / $1,490.92
| Facility | | $1,490.92 | $1,490.92 | $1,490.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,274.40 / $1,936.26 / $3,757.35
| Professional | | $1,274.40 | $1,936.26 | $3,757.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,059.01 / $1,579.14 / $2,230.38
| Professional | | $1,059.01 | $1,579.14 | $2,230.38 |