- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,091.35 / $1,091.35 / $8,500.00
| Facility | | $1,091.35 | $1,091.35 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,091.35 / $1,091.35 / $1,189.86
| Professional | | $1,091.35 | $1,091.35 | $1,189.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,166.85 / $2,382.92 / $2,856.47
| Professional | | $2,166.85 | $2,382.92 | $2,856.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,384.59 / $2,664.65 / $3,441.00
| Professional | | $1,384.59 | $2,664.65 | $3,441.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,091.35 / $1,312.34 / $3,274.08
| Facility | | $1,091.35 | $1,312.34 | $3,274.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,128.16 / $2,013.98 / $2,837.60
| Professional | | $1,128.16 | $2,013.98 | $2,837.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,179.81 / $2,250.83 / $2,855.95
| Professional | | $1,179.81 | $2,250.83 | $2,855.95 |