- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,148.45 / $1,148.45 / $8,500.00
| Facility | | $1,148.45 | $1,148.45 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,034.59 / $1,148.45 / $1,737.92
| Professional | | $1,034.59 | $1,148.45 | $1,737.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,224.76 / $2,440.71 / $2,925.88
| Professional | | $2,224.76 | $2,440.71 | $2,925.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,413.58 / $2,651.58 / $3,424.12
| Professional | | $1,413.58 | $2,651.58 | $3,424.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,148.45 / $1,597.91 / $3,445.35
| Facility | | $1,148.45 | $1,597.91 | $3,445.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,246.14 / $2,127.21 / $2,966.69
| Professional | | $1,246.14 | $2,127.21 | $2,966.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,207.56 / $2,265.69 / $2,966.69
| Professional | | $1,207.56 | $2,265.69 | $2,966.69 |