- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,260.84 / $1,260.84 / $8,500.00
| Facility | | $1,260.84 | $1,260.84 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,260.84 / $1,260.84 / $1,298.78
| Professional | | $1,260.84 | $1,260.84 | $1,298.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,485.32 / $2,701.83 / $3,192.22
| Professional | | $2,485.32 | $2,701.83 | $3,192.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,649.94 / $2,242.16 / $3,619.28
| Professional | | $1,649.94 | $2,242.16 | $3,619.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,260.84 / $1,724.34 / $3,782.55
| Facility | | $1,260.84 | $1,724.34 | $3,782.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,376.46 / $2,432.23 / $3,218.54
| Professional | | $1,376.46 | $2,432.23 | $3,218.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,424.82 / $2,590.58 / $3,218.54
| Professional | | $1,424.82 | $2,590.58 | $3,218.54 |