- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,152.52 / $1,152.52 / $8,500.00
| Facility | | $1,152.52 | $1,152.52 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,152.52 / $1,152.52 / $1,210.49
| Professional | | $1,152.52 | $1,152.52 | $1,210.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,269.98 / $2,452.05 / $2,897.13
| Professional | | $2,269.98 | $2,452.05 | $2,897.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,618.12 / $2,096.42 / $3,384.04
| Professional | | $1,618.12 | $2,096.42 | $3,384.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,152.52 / $1,594.64 / $3,457.56
| Facility | | $1,152.52 | $1,594.64 | $3,457.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.84 / $2,186.48 / $2,958.03
| Professional | | $1,202.84 | $2,186.48 | $2,958.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,280.85 / $2,487.48 / $2,983.62
| Professional | | $1,280.85 | $2,487.48 | $2,983.62 |