- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,113.39 / $1,113.39 / $8,500.00
| Facility | | $1,113.39 | $1,113.39 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,016.14 / $1,091.16 / $1,181.80
| Professional | | $1,016.14 | $1,091.16 | $1,181.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,958.40 / $2,194.42 / $2,581.67
| Professional | | $1,958.40 | $2,194.42 | $2,581.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,246.50 / $2,490.35 / $3,317.15
| Professional | | $1,246.50 | $2,490.35 | $3,317.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,113.39 / $1,310.61 / $1,892.76
| Facility | | $1,113.39 | $1,310.61 | $1,892.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,149.81 / $2,109.55 / $2,894.69
| Professional | | $1,149.81 | $2,109.55 | $2,894.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,149.81 / $2,036.72 / $2,745.74
| Professional | | $1,149.81 | $2,036.72 | $2,745.74 |