- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,116.81 / $1,116.81 / $8,500.00
| Facility | | $1,116.81 | $1,116.81 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,116.81 / $1,116.81 / $1,166.65
| Professional | | $1,116.81 | $1,116.81 | $1,166.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,194.52 / $2,386.11 / $2,819.21
| Professional | | $2,194.52 | $2,386.11 | $2,819.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,556.58 / $2,016.70 / $3,255.34
| Professional | | $1,556.58 | $2,016.70 | $3,255.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,116.81 / $1,538.78 / $3,350.43
| Facility | | $1,116.81 | $1,538.78 | $3,350.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,155.90 / $2,111.69 / $2,864.92
| Professional | | $1,155.90 | $2,111.69 | $2,864.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,237.05 / $2,410.41 / $2,864.92
| Professional | | $1,237.05 | $2,410.41 | $2,864.92 |