- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,310.75 / $1,310.75 / $8,500.00
| Facility | | $1,310.75 | $1,310.75 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,240.50 / $1,268.38 / $1,347.15
| Professional | | $1,240.50 | $1,268.38 | $1,347.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,633.39 / $2,896.86 / $3,396.72
| Professional | | $2,633.39 | $2,896.86 | $3,396.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,585.27 / $3,167.16 / $4,218.66
| Professional | | $1,585.27 | $3,167.16 | $4,218.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,310.75 / $1,619.35 / $2,228.28
| Facility | | $1,310.75 | $1,619.35 | $2,228.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,385.84 / $2,447.27 / $3,383.86
| Professional | | $1,385.84 | $2,447.27 | $3,383.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,385.84 / $2,447.27 / $3,048.85
| Professional | | $1,385.84 | $2,447.27 | $3,048.85 |