- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,178.08 / $1,178.08 / $8,500.00
| Facility | | $1,178.08 | $1,178.08 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,178.08 / $1,178.08 / $1,214.45
| Professional | | $1,178.08 | $1,178.08 | $1,214.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,330.03 / $2,525.71 / $2,984.16
| Professional | | $2,330.03 | $2,525.71 | $2,984.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,534.79 / $2,096.42 / $3,384.04
| Professional | | $1,534.79 | $2,096.42 | $3,384.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,178.08 / $1,611.87 / $3,534.24
| Facility | | $1,178.08 | $1,611.87 | $3,534.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,285.51 / $2,249.56 / $3,007.77
| Professional | | $1,285.51 | $2,249.56 | $3,007.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,319.03 / $2,542.65 / $2,984.31
| Professional | | $1,319.03 | $2,542.65 | $2,984.31 |