- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,340.38 / $1,340.38 / $8,500.00
| Facility | | $1,340.38 | $1,340.38 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,340.38 / $1,340.38 / $1,482.21
| Professional | | $1,340.38 | $1,340.38 | $1,482.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,779.34 / $3,035.39 / $3,638.77
| Professional | | $2,779.34 | $3,035.39 | $3,638.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,762.26 / $3,354.09 / $4,331.32
| Professional | | $1,762.26 | $3,354.09 | $4,331.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,340.38 / $2,011.92 / $4,021.14
| Facility | | $1,340.38 | $2,011.92 | $4,021.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.39 / $2,529.57 / $3,436.70
| Professional | | $1,445.39 | $2,529.57 | $3,436.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.39 / $2,694.26 / $3,436.70
| Professional | | $1,445.39 | $2,694.26 | $3,436.70 |