- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,053.35 / $1,053.35 / $8,500.00
| Facility | | $1,053.35 | $1,053.35 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,053.35 / $1,071.57 / $1,630.33
| Professional | | $1,053.35 | $1,071.57 | $1,630.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,083.21 / $2,261.92 / $2,672.48
| Professional | | $2,083.21 | $2,261.92 | $2,672.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,486.47 / $1,925.86 / $3,108.72
| Professional | | $1,486.47 | $1,925.86 | $3,108.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,053.35 / $1,465.61 / $3,160.08
| Facility | | $1,053.35 | $1,465.61 | $3,160.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.14 / $1,994.04 / $2,705.39
| Professional | | $1,071.14 | $1,994.04 | $2,705.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,168.11 / $2,123.86 / $2,705.39
| Professional | | $1,168.11 | $2,123.86 | $2,705.39 |