- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,278.21 / $1,278.21 / $8,500.00
| Facility | | $1,278.21 | $1,278.21 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,278.21 / $1,278.21 / $1,342.36
| Professional | | $1,278.21 | $1,278.21 | $1,342.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,532.76 / $2,741.11 / $3,238.64
| Professional | | $2,532.76 | $2,741.11 | $3,238.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,736.23 / $2,329.07 / $3,759.57
| Professional | | $1,736.23 | $2,329.07 | $3,759.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,278.21 / $1,773.84 / $3,834.63
| Facility | | $1,278.21 | $1,773.84 | $3,834.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,246.22 / $2,533.92 / $3,281.55
| Professional | | $1,246.22 | $2,533.92 | $3,281.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,484.40 / $2,698.90 / $3,281.55
| Professional | | $1,484.40 | $2,698.90 | $3,281.55 |