- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,270.56 / $1,270.56 / $8,500.00
| Facility | | $1,270.56 | $1,270.56 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,069.39 / $1,217.38 / $1,270.56
| Professional | | $1,069.39 | $1,217.38 | $1,270.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,416.55 / $2,698.34 / $3,174.51
| Professional | | $2,416.55 | $2,698.34 | $3,174.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,508.39 / $3,013.57 / $4,014.08
| Professional | | $1,508.39 | $3,013.57 | $4,014.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,270.56 / $1,496.93 / $2,159.94
| Facility | | $1,270.56 | $1,496.93 | $2,159.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,325.57 / $2,285.98 / $3,295.44
| Professional | | $1,325.57 | $2,285.98 | $3,295.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,325.57 / $2,285.98 / $2,916.25
| Professional | | $1,325.57 | $2,285.98 | $2,916.25 |