- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,158.82 / $1,158.82 / $8,500.00
| Facility | | $1,158.82 | $1,158.82 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,127.49 / $1,158.82 / $1,158.82
| Professional | | $1,127.49 | $1,158.82 | $1,158.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,431.92 / $2,645.75 / $3,171.67
| Professional | | $2,431.92 | $2,645.75 | $3,171.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,498.67 / $2,731.63 / $3,527.50
| Professional | | $1,498.67 | $2,731.63 | $3,527.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,158.82 / $1,525.07 / $3,476.46
| Facility | | $1,158.82 | $1,525.07 | $3,476.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,271.08 / $2,175.54 / $2,962.36
| Professional | | $1,271.08 | $2,175.54 | $2,962.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,274.45 / $2,317.17 / $2,962.36
| Professional | | $1,274.45 | $2,317.17 | $2,962.36 |