- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,157.35 / $1,157.35 / $8,500.00
| Facility | | $1,157.35 | $1,157.35 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,157.35 / $1,157.35 / $1,189.39
| Professional | | $1,157.35 | $1,157.35 | $1,189.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,277.52 / $2,478.01 / $2,927.80
| Professional | | $2,277.52 | $2,478.01 | $2,927.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,584.82 / $2,053.30 / $3,314.42
| Professional | | $1,584.82 | $2,053.30 | $3,314.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,157.35 / $1,579.56 / $3,472.08
| Facility | | $1,157.35 | $1,579.56 | $3,472.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,263.85 / $2,497.92 / $2,953.99
| Professional | | $1,263.85 | $2,497.92 | $2,953.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,625.93 / $2,580.54 / $2,922.46
| Professional | | $1,625.93 | $2,580.54 | $2,922.46 |