- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,230.60 / $1,230.60 / $8,500.00
| Facility | | $1,230.60 | $1,230.60 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,151.65 / $1,191.61 / $1,259.83
| Professional | | $1,151.65 | $1,191.61 | $1,259.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,476.23 / $2,723.98 / $3,194.02
| Professional | | $2,476.23 | $2,723.98 | $3,194.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,492.34 / $2,981.50 / $3,971.36
| Professional | | $1,492.34 | $2,981.50 | $3,971.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,230.60 / $1,618.54 / $2,161.05
| Facility | | $1,230.60 | $1,618.54 | $2,161.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,300.31 / $2,300.69 / $3,177.80
| Professional | | $1,300.31 | $2,300.69 | $3,177.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,300.31 / $2,353.78 / $3,286.47
| Professional | | $1,300.31 | $2,353.78 | $3,286.47 |