- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.49 / $1,288.49 / $10,500.00
| Facility | | $1,288.49 | $1,288.49 | $10,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.49 / $1,305.32 / $1,403.82
| Professional | | $1,288.49 | $1,305.32 | $1,403.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,495.62 / $2,715.16 / $3,207.97
| Professional | | $2,495.62 | $2,715.16 | $3,207.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,573.31 / $2,292.48 / $3,700.50
| Professional | | $1,573.31 | $2,292.48 | $3,700.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.49 / $1,750.61 / $3,865.47
| Facility | | $1,288.49 | $1,750.61 | $3,865.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,390.53 / $2,460.57 / $3,034.05
| Professional | | $1,390.53 | $2,460.57 | $3,034.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,441.42 / $2,620.76 / $3,034.05
| Professional | | $1,441.42 | $2,620.76 | $3,034.05 |