- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,234.98 / $1,234.98 / $8,500.00
| Facility | | $1,234.98 | $1,234.98 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,234.98 / $1,258.31 / $1,295.70
| Professional | | $1,234.98 | $1,258.31 | $1,295.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,437.71 / $2,646.40 / $3,126.74
| Professional | | $2,437.71 | $2,646.40 | $3,126.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,734.13 / $2,246.73 / $3,626.66
| Professional | | $1,734.13 | $2,246.73 | $3,626.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,234.98 / $1,712.10 / $3,704.94
| Facility | | $1,234.98 | $1,712.10 | $3,704.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,281.24 / $2,450.60 / $3,169.98
| Professional | | $1,281.24 | $2,450.60 | $3,169.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,435.58 / $2,610.14 / $3,169.98
| Professional | | $1,435.58 | $2,610.14 | $3,169.98 |