- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.58 / $1,202.58 / $8,500.00
| Facility | | $1,202.58 | $1,202.58 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.58 / $1,219.57 / $1,852.67
| Professional | | $1,202.58 | $1,219.57 | $1,852.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,374.02 / $2,576.94 / $3,044.68
| Professional | | $2,374.02 | $2,576.94 | $3,044.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,690.24 / $2,189.88 / $3,534.89
| Professional | | $1,690.24 | $2,189.88 | $3,534.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.58 / $1,668.05 / $3,607.77
| Facility | | $1,202.58 | $1,668.05 | $3,607.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,219.96 / $2,384.71 / $3,087.25
| Professional | | $1,219.96 | $2,384.71 | $3,087.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,292.73 / $2,539.98 / $3,087.25
| Professional | | $1,292.73 | $2,539.98 | $3,087.25 |