- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,310.58 / $1,310.58 / $8,500.00
| Facility | | $1,310.58 | $1,310.58 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,176.73 / $1,310.58 / $1,310.58
| Professional | | $1,176.73 | $1,310.58 | $1,310.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,530.36 / $2,777.51 / $3,329.62
| Professional | | $2,530.36 | $2,777.51 | $3,329.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,609.84 / $3,015.09 / $3,893.54
| Professional | | $1,609.84 | $3,015.09 | $3,893.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,310.58 / $1,817.12 / $3,931.77
| Facility | | $1,310.58 | $1,817.12 | $3,931.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,419.28 / $2,422.77 / $3,384.62
| Professional | | $1,419.28 | $2,422.77 | $3,384.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,419.28 / $2,546.73 / $3,384.62
| Professional | | $1,419.28 | $2,546.73 | $3,384.62 |