- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,426.40 / $1,426.40 / $8,500.00
| Facility | | $1,426.40 | $1,426.40 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,426.40 / $1,426.40 / $1,432.78
| Professional | | $1,426.40 | $1,426.40 | $1,432.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,818.58 / $3,074.14 / $3,685.23
| Professional | | $2,818.58 | $3,074.14 | $3,685.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,766.72 / $3,251.16 / $4,198.39
| Professional | | $1,766.72 | $3,251.16 | $4,198.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,426.40 / $1,981.05 / $4,279.20
| Facility | | $1,426.40 | $1,981.05 | $4,279.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,533.09 / $2,693.88 / $3,662.07
| Professional | | $1,533.09 | $2,693.88 | $3,662.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,533.09 / $2,869.26 / $3,662.07
| Professional | | $1,533.09 | $2,869.26 | $3,662.07 |