- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,284.53 / $1,284.53 / $8,500.00
| Facility | | $1,284.53 | $1,284.53 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,182.19 / $1,276.10 / $1,332.79
| Professional | | $1,182.19 | $1,276.10 | $1,332.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,586.87 / $2,851.29 / $3,343.28
| Professional | | $2,586.87 | $2,851.29 | $3,343.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,566.68 / $3,130.03 / $4,169.20
| Professional | | $1,566.68 | $3,130.03 | $4,169.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,284.53 / $1,672.51 / $2,184.94
| Facility | | $1,284.53 | $1,672.51 | $2,184.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,355.53 / $2,398.48 / $3,318.75
| Professional | | $1,355.53 | $2,398.48 | $3,318.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,355.53 / $2,219.04 / $2,772.40
| Professional | | $1,355.53 | $2,219.04 | $2,772.40 |