- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,407.07 / $1,407.07 / $8,500.00
| Facility | | $1,407.07 | $1,407.07 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,407.07 / $1,407.07 / $1,473.43
| Professional | | $1,407.07 | $1,407.07 | $1,473.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,756.82 / $2,990.88 / $3,533.75
| Professional | | $2,756.82 | $2,990.88 | $3,533.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,734.72 / $2,548.65 / $4,114.01
| Professional | | $1,734.72 | $2,548.65 | $4,114.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,407.07 / $1,940.81 / $4,221.21
| Facility | | $1,407.07 | $1,940.81 | $4,221.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,351.26 / $2,672.34 / $3,609.81
| Professional | | $1,351.26 | $2,672.34 | $3,609.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,565.48 / $2,846.32 / $3,609.81
| Professional | | $1,565.48 | $2,846.32 | $3,609.81 |