- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.42 / $1,202.42 / $8,500.00
| Facility | | $1,202.42 | $1,202.42 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,163.32 / $1,202.42 / $1,202.42
| Professional | | $1,163.32 | $1,202.42 | $1,202.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,516.19 / $2,742.28 / $3,287.39
| Professional | | $2,516.19 | $2,742.28 | $3,287.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,554.54 / $2,809.23 / $3,627.72
| Professional | | $1,554.54 | $2,809.23 | $3,627.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.42 / $1,727.48 / $3,607.26
| Facility | | $1,202.42 | $1,727.48 | $3,607.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,323.04 / $2,280.44 / $3,070.35
| Professional | | $1,323.04 | $2,280.44 | $3,070.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,457.35 / $2,729.01 / $3,198.35
| Professional | | $1,457.35 | $2,729.01 | $3,198.35 |