- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,206.72 / $1,206.72 / $8,500.00
| Facility | | $1,206.72 | $1,206.72 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,112.78 / $1,200.56 / $1,251.39
| Professional | | $1,112.78 | $1,200.56 | $1,251.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,438.76 / $2,682.76 / $3,145.68
| Professional | | $2,438.76 | $2,682.76 | $3,145.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,475.44 / $2,947.74 / $3,926.40
| Professional | | $1,475.44 | $2,947.74 | $3,926.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,206.72 / $1,616.51 / $2,056.88
| Facility | | $1,206.72 | $1,616.51 | $2,056.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,272.52 / $2,251.01 / $3,118.55
| Professional | | $1,272.52 | $2,251.01 | $3,118.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,272.52 / $2,213.73 / $2,799.54
| Professional | | $1,272.52 | $2,213.73 | $2,799.54 |