- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,210.54 / $1,210.54 / $8,500.00
| Facility | | $1,210.54 | $1,210.54 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,042.75 / $1,207.21 / $1,256.36
| Professional | | $1,042.75 | $1,207.21 | $1,256.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,451.25 / $2,696.50 / $3,161.79
| Professional | | $2,451.25 | $2,696.50 | $3,161.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,484.74 / $2,966.31 / $3,951.13
| Professional | | $1,484.74 | $2,966.31 | $3,951.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,210.54 / $1,723.98 / $2,176.05
| Facility | | $1,210.54 | $1,723.98 | $2,176.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,275.41 / $2,220.73 / $3,129.45
| Professional | | $1,275.41 | $2,220.73 | $3,129.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,275.41 / $2,142.29 / $2,805.90
| Professional | | $1,275.41 | $2,142.29 | $2,805.90 |