- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,096.33 / $1,096.33 / $8,500.00
| Facility | | $1,096.33 | $1,096.33 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.33 / $1,096.33 / $1,127.26
| Professional | | $1,096.33 | $1,096.33 | $1,127.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,167.33 / $2,346.82 / $2,772.78
| Professional | | $2,167.33 | $2,346.82 | $2,772.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,449.46 / $1,945.47 / $3,140.36
| Professional | | $1,449.46 | $1,945.47 | $3,140.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,096.33 / $1,497.33 / $3,289.02
| Facility | | $1,096.33 | $1,497.33 | $3,289.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,197.45 / $2,131.30 / $2,798.08
| Professional | | $1,197.45 | $2,131.30 | $2,798.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,248.53 / $2,270.06 / $2,798.08
| Professional | | $1,248.53 | $2,270.06 | $2,798.08 |