- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,272.17 / $1,272.17 / $8,500.00
| Facility | | $1,272.17 | $1,272.17 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,272.17 / $1,272.17 / $1,368.68
| Professional | | $1,272.17 | $1,272.17 | $1,368.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,480.17 / $2,721.85 / $3,262.90
| Professional | | $2,480.17 | $2,721.85 | $3,262.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,580.48 / $3,072.27 / $3,967.38
| Professional | | $1,580.48 | $3,072.27 | $3,967.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,272.17 / $1,705.14 / $3,816.51
| Facility | | $1,272.17 | $1,705.14 | $3,816.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,308.97 / $2,342.81 / $3,314.55
| Professional | | $1,308.97 | $2,342.81 | $3,314.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,308.97 / $2,495.34 / $3,314.55
| Professional | | $1,308.97 | $2,495.34 | $3,314.55 |