- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,227.83 / $1,227.83 / $8,500.00
| Facility | | $1,227.83 | $1,227.83 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,155.57 / $1,227.83 / $1,227.83
| Professional | | $1,155.57 | $1,227.83 | $1,227.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,359.21 / $2,567.54 / $3,077.92
| Professional | | $2,359.21 | $2,567.54 | $3,077.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,480.15 / $2,865.60 / $3,700.50
| Professional | | $1,480.15 | $2,865.60 | $3,700.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,227.83 / $1,636.49 / $3,683.49
| Facility | | $1,227.83 | $1,636.49 | $3,683.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,275.41 / $2,310.03 / $3,181.63
| Professional | | $1,275.41 | $2,310.03 | $3,181.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,275.41 / $2,460.42 / $3,181.63
| Professional | | $1,275.41 | $2,460.42 | $3,181.63 |