- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,058.01 / $1,058.01 / $8,500.00
| Facility | | $1,058.01 | $1,058.01 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,058.01 / $1,167.44 / $1,583.13
| Professional | | $1,058.01 | $1,167.44 | $1,583.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,083.21 / $2,264.73 / $2,675.79
| Professional | | $2,083.21 | $2,264.73 | $2,675.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,310.07 / $1,878.16 / $3,031.71
| Professional | | $1,310.07 | $1,878.16 | $3,031.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,058.01 / $1,444.76 / $3,174.03
| Facility | | $1,058.01 | $1,444.76 | $3,174.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,152.32 / $2,031.89 / $2,700.28
| Professional | | $1,152.32 | $2,031.89 | $2,700.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,190.30 / $2,164.17 / $2,700.28
| Professional | | $1,190.30 | $2,164.17 | $2,700.28 |