- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,068.85 / $1,068.85 / $8,500.00
| Facility | | $1,068.85 | $1,068.85 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $906.83 / $1,068.85 / $1,244.47
| Professional | | $906.83 | $1,068.85 | $1,244.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,254.35 / $2,526.04 / $2,971.82
| Professional | | $2,254.35 | $2,526.04 | $2,971.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,325.07 / $2,647.31 / $3,526.23
| Professional | | $1,325.07 | $2,647.31 | $3,526.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,068.85 / $1,284.20 / $1,877.62
| Facility | | $1,068.85 | $1,284.20 | $1,877.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,165.69 / $1,951.84 / $2,738.16
| Professional | | $1,165.69 | $1,951.84 | $2,738.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,165.69 / $1,951.84 / $2,306.92
| Professional | | $1,165.69 | $1,951.84 | $2,306.92 |