- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,229.55 / $1,229.55 / $8,500.00
| Facility | | $1,229.55 | $1,229.55 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,128.52 / $1,229.55 / $1,629.68
| Professional | | $1,128.52 | $1,229.55 | $1,629.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,500.56 / $2,750.74 / $3,225.40
| Professional | | $2,500.56 | $2,750.74 | $3,225.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,369.21 / $2,434.56 / $3,651.98
| Professional | | $1,369.21 | $2,434.56 | $3,651.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,229.55 / $1,707.31 / $3,671.46
| Facility | | $1,229.55 | $1,707.31 | $3,671.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,147.33 / $2,255.61 / $9,094.16
| Professional | | $1,147.33 | $2,255.61 | $9,094.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,960.00 / $3,960.00 / $3,960.00
| Facility | | $3,960.00 | $3,960.00 | $3,960.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,147.15 / $2,278.75 / $3,156.45
| Professional | | $1,147.15 | $2,278.75 | $3,156.45 |