- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,196.26 / $1,196.26 / $8,500.00
| Facility | | $1,196.26 | $1,196.26 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,196.26 / $1,196.26 / $1,234.50
| Professional | | $1,196.26 | $1,196.26 | $1,234.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,367.46 / $2,566.41 / $3,032.24
| Professional | | $2,367.46 | $2,566.41 | $3,032.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,611.54 / $2,129.76 / $3,437.84
| Professional | | $1,611.54 | $2,129.76 | $3,437.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,196.26 / $1,637.67 / $3,588.78
| Facility | | $1,196.26 | $1,637.67 | $3,588.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,305.35 / $2,288.36 / $3,054.17
| Professional | | $1,305.35 | $2,288.36 | $3,054.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,305.35 / $2,310.48 / $3,054.17
| Professional | | $1,305.35 | $2,310.48 | $3,054.17 |