- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,075.65 / $1,075.65 / $8,500.00
| Facility | | $1,075.65 | $1,075.65 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,075.65 / $1,075.65 / $1,105.60
| Professional | | $1,075.65 | $1,075.65 | $1,105.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,116.67 / $2,302.62 / $2,720.56
| Professional | | $2,116.67 | $2,302.62 | $2,720.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,455.66 / $1,908.22 / $3,080.24
| Professional | | $1,455.66 | $1,908.22 | $3,080.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,075.65 / $1,468.11 / $3,226.95
| Facility | | $1,075.65 | $1,468.11 | $3,226.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.72 / $2,245.54 / $2,745.38
| Professional | | $1,174.72 | $2,245.54 | $2,745.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,315.46 / $2,391.73 / $2,745.38
| Professional | | $1,315.46 | $2,391.73 | $2,745.38 |