- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,210.19 / $1,210.19 / $8,500.00
| Facility | | $1,210.19 | $1,210.19 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,210.19 / $1,210.19 / $1,326.63
| Professional | | $1,210.19 | $1,210.19 | $1,326.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,402.96 / $2,647.86 / $3,167.73
| Professional | | $2,402.96 | $2,647.86 | $3,167.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,540.50 / $2,962.81 / $3,826.03
| Professional | | $1,540.50 | $2,962.81 | $3,826.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,210.19 / $1,759.49 / $3,630.57
| Facility | | $1,210.19 | $1,759.49 | $3,630.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,249.78 / $2,748.35 / $3,148.01
| Professional | | $1,249.78 | $2,748.35 | $3,148.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,679.55 / $2,599.54 / $3,148.01
| Professional | | $1,679.55 | $2,599.54 | $3,148.01 |