- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,255.96 / $1,255.96 / $8,500.00
| Facility | | $1,255.96 | $1,255.96 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,185.75 / $1,255.96 / $1,277.20
| Professional | | $1,185.75 | $1,255.96 | $1,277.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,421.62 / $2,633.06 / $3,156.47
| Professional | | $2,421.62 | $2,633.06 | $3,156.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,516.78 / $2,944.02 / $3,801.77
| Professional | | $1,516.78 | $2,944.02 | $3,801.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,255.96 / $1,762.31 / $3,767.88
| Facility | | $1,255.96 | $1,762.31 | $3,767.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,303.92 / $2,357.50 / $3,255.38
| Professional | | $1,303.92 | $2,357.50 | $3,255.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,381.04 / $2,510.98 / $3,255.38
| Professional | | $1,381.04 | $2,510.98 | $3,255.38 |