- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,148.29 / $1,148.29 / $8,500.00
| Facility | | $1,148.29 | $1,148.29 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,050.27 / $1,148.29 / $1,206.82
| Professional | | $1,050.27 | $1,148.29 | $1,206.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,342.10 / $2,581.48 / $3,026.94
| Professional | | $2,342.10 | $2,581.48 | $3,026.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,465.82 / $2,879.39 / $3,835.35
| Professional | | $1,465.82 | $2,879.39 | $3,835.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,148.29 / $1,653.53 / $1,996.45
| Facility | | $1,148.29 | $1,653.53 | $1,996.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,200.70 / $2,106.54 / $2,977.61
| Professional | | $1,200.70 | $2,106.54 | $2,977.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,200.70 / $2,106.54 / $2,977.61
| Professional | | $1,200.70 | $2,106.54 | $2,977.61 |