- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,263.58 / $1,263.58 / $8,500.00
| Facility | | $1,263.58 | $1,263.58 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,263.58 / $1,263.58 / $1,324.21
| Professional | | $1,263.58 | $1,263.58 | $1,324.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,417.12 / $2,650.68 / $3,177.59
| Professional | | $2,417.12 | $2,650.68 | $3,177.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,539.17 / $2,975.88 / $3,842.91
| Professional | | $1,539.17 | $2,975.88 | $3,842.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,263.58 / $1,520.57 / $3,790.77
| Facility | | $1,263.58 | $1,520.57 | $3,790.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,303.92 / $2,443.50 / $3,288.04
| Professional | | $1,303.92 | $2,443.50 | $3,288.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,431.42 / $2,602.58 / $3,288.04
| Professional | | $1,431.42 | $2,602.58 | $3,288.04 |