- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,481.30 / $3,150.00 / $3,150.00
| Facility | | $1,481.30 | $3,150.00 | $3,150.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,452.25 / $1,481.30 / $1,742.70
| Professional | | $1,452.25 | $1,481.30 | $1,742.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,229.27 / $1,513.74 / $2,036.40
| Professional | | $1,229.27 | $1,513.74 | $2,036.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,370.05 / $1,370.05 / $1,452.25
| Facility | | $1,370.05 | $1,370.05 | $1,452.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,452.25 / $1,452.25 / $1,849.57
| Professional | | $1,452.25 | $1,452.25 | $1,849.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,759.54 / $2,070.00 / $4,299.83
| Facility | | $1,759.54 | $2,070.00 | $4,299.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,644.99 / $1,725.04 / $6,878.66
| Professional | | $1,644.99 | $1,725.04 | $6,878.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,452.25 / $1,452.25 / $1,452.25
| Facility | | $1,452.25 | $1,452.25 | $1,452.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,452.25 / $1,452.25 / $1,810.96
| Professional | | $1,452.25 | $1,452.25 | $1,810.96 |