- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,146.23 / $1,146.23 / $8,500.00
| Facility | | $1,146.23 | $1,146.23 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,146.23 / $1,146.23 / $1,204.35
| Professional | | $1,146.23 | $1,146.23 | $1,204.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,262.71 / $2,457.67 / $2,903.76
| Professional | | $2,262.71 | $2,457.67 | $2,903.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,612.06 / $2,088.59 / $3,371.38
| Professional | | $1,612.06 | $2,088.59 | $3,371.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,146.23 / $1,590.68 / $3,438.69
| Facility | | $1,146.23 | $1,590.68 | $3,438.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,186.14 / $2,168.26 / $2,942.73
| Professional | | $1,186.14 | $2,168.26 | $2,942.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,270.18 / $2,309.42 / $2,942.73
| Professional | | $1,270.18 | $2,309.42 | $2,942.73 |