- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.06 / $1,202.06 / $8,500.00
| Facility | | $1,202.06 | $1,202.06 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,162.52 / $1,202.06 / $1,202.06
| Professional | | $1,162.52 | $1,202.06 | $1,202.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,514.27 / $2,740.16 / $3,284.85
| Professional | | $2,514.27 | $2,740.16 | $3,284.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,553.36 / $2,807.60 / $3,625.61
| Professional | | $1,553.36 | $2,807.60 | $3,625.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.06 / $1,726.25 / $3,606.18
| Facility | | $1,202.06 | $1,726.25 | $3,606.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,322.68 / $2,298.14 / $3,069.42
| Professional | | $1,322.68 | $2,298.14 | $3,069.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,346.27 / $2,370.86 / $3,069.42
| Professional | | $1,346.27 | $2,370.86 | $3,069.42 |