- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,086.75 / $1,086.75 / $10,500.00
| Facility | | $1,086.75 | $1,086.75 | $10,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $942.87 / $1,086.75 / $1,369.14
| Professional | | $942.87 | $1,086.75 | $1,369.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,221.12 / $2,443.34 / $2,864.94
| Professional | | $2,221.12 | $2,443.34 | $2,864.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,351.26 / $2,699.64 / $3,595.92
| Professional | | $1,351.26 | $2,699.64 | $3,595.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,086.75 / $1,402.00 / $1,879.34
| Facility | | $1,086.75 | $1,402.00 | $1,879.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,139.34 / $1,993.64 / $2,814.04
| Professional | | $1,139.34 | $1,993.64 | $2,814.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,139.34 / $1,993.64 / $2,506.57
| Professional | | $1,139.34 | $1,993.64 | $2,506.57 |