- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,192.17 / $1,192.17 / $9,500.00
| Facility | | $1,192.17 | $1,192.17 | $9,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,057.52 / $1,186.06 / $1,237.08
| Professional | | $1,057.52 | $1,186.06 | $1,237.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,227.07 / $2,451.53 / $3,265.44
| Professional | | $1,227.07 | $2,451.53 | $3,265.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,192.17 / $1,684.38 / $2,021.26
| Facility | | $1,192.17 | $1,684.38 | $2,021.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,182.85 / $1,987.52 / $2,386.25
| Professional | | $1,182.85 | $1,987.52 | $2,386.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,255.92 / $1,987.52 / $2,363.55
| Professional | | $1,255.92 | $1,987.52 | $2,363.55 |