- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,170.84 / $1,170.84 / $8,500.00
| Facility | | $1,170.84 | $1,170.84 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,170.84 / $1,170.84 / $1,203.81
| Professional | | $1,170.84 | $1,170.84 | $1,203.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,305.17 / $2,507.48 / $2,962.61
| Professional | | $2,305.17 | $2,507.48 | $2,962.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,450.35 / $2,077.48 / $3,353.45
| Professional | | $1,450.35 | $2,077.48 | $3,353.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,170.84 / $1,598.55 / $3,512.55
| Facility | | $1,170.84 | $1,598.55 | $3,512.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,221.55 / $2,236.16 / $2,988.35
| Professional | | $1,221.55 | $2,236.16 | $2,988.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,278.65 / $2,381.73 / $2,988.35
| Professional | | $1,278.65 | $2,381.73 | $2,988.35 |