- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,320.53 / $1,320.53 / $8,500.00
| Facility | | $1,320.53 | $1,320.53 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,249.32 / $1,320.53 / $1,555.52
| Professional | | $1,249.32 | $1,320.53 | $1,555.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,856.28 / $3,142.05 / $3,684.23
| Professional | | $2,856.28 | $3,142.05 | $3,684.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,611.03 / $3,218.63 / $4,287.22
| Professional | | $1,611.03 | $3,218.63 | $4,287.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,320.53 / $1,756.41 / $2,345.15
| Facility | | $1,320.53 | $1,756.41 | $2,345.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,443.94 / $2,545.46 / $3,377.63
| Professional | | $1,443.94 | $2,545.46 | $3,377.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,443.94 / $2,555.77 / $3,377.63
| Professional | | $1,443.94 | $2,555.77 | $3,377.63 |