- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,188.52 / $1,188.52 / $8,500.00
| Facility | | $1,188.52 | $1,188.52 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,116.08 / $1,188.52 / $1,188.52
| Professional | | $1,116.08 | $1,188.52 | $1,188.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,280.08 / $2,480.87 / $2,974.03
| Professional | | $2,280.08 | $2,480.87 | $2,974.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,431.54 / $2,765.94 / $3,571.81
| Professional | | $1,431.54 | $2,765.94 | $3,571.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,188.52 / $1,657.44 / $3,565.56
| Facility | | $1,188.52 | $1,657.44 | $3,565.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,234.99 / $2,321.89 / $3,079.16
| Professional | | $1,234.99 | $2,321.89 | $3,079.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,978.00 / $1,978.00 / $1,978.00
| Facility | | $1,978.00 | $1,978.00 | $1,978.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,234.99 / $2,473.06 / $3,079.16
| Professional | | $1,234.99 | $2,473.06 | $3,079.16 |