- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,286.07 / $1,286.07 / $8,500.00
| Facility | | $1,286.07 | $1,286.07 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,066.83 / $1,243.89 / $1,319.19
| Professional | | $1,066.83 | $1,243.89 | $1,319.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,578.34 / $2,841.89 / $3,332.26
| Professional | | $2,578.34 | $2,841.89 | $3,332.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,554.85 / $3,106.40 / $4,137.72
| Professional | | $1,554.85 | $3,106.40 | $4,137.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,286.07 / $1,588.61 / $2,186.32
| Facility | | $1,286.07 | $1,588.61 | $2,186.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,359.86 / $2,401.69 / $3,320.02
| Professional | | $1,359.86 | $2,401.69 | $3,320.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,359.86 / $2,377.26 / $2,991.69
| Professional | | $1,359.86 | $2,377.26 | $2,991.69 |