- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,257.86 / $1,257.86 / $8,500.00
| Facility | | $1,257.86 | $1,257.86 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,257.86 / $1,257.86 / $1,321.69
| Professional | | $1,257.86 | $1,257.86 | $1,321.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,483.39 / $2,698.32 / $3,188.08
| Professional | | $2,483.39 | $2,698.32 | $3,188.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,581.24 / $2,292.48 / $3,700.50
| Professional | | $1,581.24 | $2,292.48 | $3,700.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,257.86 / $1,746.08 / $3,773.61
| Facility | | $1,257.86 | $1,746.08 | $3,773.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,246.61 / $2,382.36 / $3,229.47
| Professional | | $1,246.61 | $2,382.36 | $3,229.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,395.60 / $2,537.46 / $3,229.47
| Professional | | $1,395.60 | $2,537.46 | $3,229.47 |