- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,108.15 / $1,108.15 / $8,500.00
| Facility | | $1,108.15 | $1,108.15 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,050.82 / $1,108.15 / $1,400.09
| Professional | | $1,050.82 | $1,108.15 | $1,400.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,228.16 / $2,471.96 / $2,908.20
| Professional | | $2,228.16 | $2,471.96 | $2,908.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,365.97 / $2,679.38 / $3,568.94
| Professional | | $1,365.97 | $2,679.38 | $3,568.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,108.15 / $1,470.02 / $1,883.86
| Facility | | $1,108.15 | $1,470.02 | $1,883.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,181.93 / $2,096.86 / $2,853.35
| Professional | | $1,181.93 | $2,096.86 | $2,853.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,181.93 / $2,096.86 / $2,953.85
| Professional | | $1,181.93 | $2,096.86 | $2,953.85 |