- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,203.82 / $1,203.82 / $8,500.00
| Facility | | $1,203.82 | $1,203.82 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,203.82 / $1,203.82 / $1,320.70
| Professional | | $1,203.82 | $1,203.82 | $1,320.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,368.87 / $2,609.81 / $3,122.78
| Professional | | $2,368.87 | $2,609.81 | $3,122.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,516.54 / $2,943.20 / $3,800.71
| Professional | | $1,516.54 | $2,943.20 | $3,800.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,203.82 / $1,464.29 / $3,611.46
| Facility | | $1,203.82 | $1,464.29 | $3,611.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,102.33 / $2,004.26 / $3,139.35
| Professional | | $1,102.33 | $2,004.26 | $3,139.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.56 / $2,004.26 / $3,139.35
| Professional | | $1,202.56 | $2,004.26 | $3,139.35 |