- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,172.54 / $1,172.54 / $8,500.00
| Facility | | $1,172.54 | $1,172.54 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,172.54 / $1,172.54 / $1,288.13
| Professional | | $1,172.54 | $1,172.54 | $1,288.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,330.91 / $2,570.36 / $3,072.74
| Professional | | $2,330.91 | $2,570.36 | $3,072.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,493.53 / $2,876.22 / $3,714.21
| Professional | | $1,493.53 | $2,876.22 | $3,714.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,172.54 / $1,707.48 / $3,517.62
| Facility | | $1,172.54 | $1,707.48 | $3,517.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,210.08 / $2,196.73 / $3,050.83
| Professional | | $1,210.08 | $2,196.73 | $3,050.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,210.08 / $2,339.76 / $3,050.83
| Professional | | $1,210.08 | $2,339.76 | $3,050.83 |