- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,071.52 / $8,500.00
| Facility | | $1,071.52 | $1,071.52 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,088.47 / $1,167.06
| Professional | | $1,071.52 | $1,088.47 | $1,167.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,157.34 / $2,373.17 / $2,782.68
| Professional | | $2,157.34 | $2,373.17 | $2,782.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,341.96 / $2,681.07 / $3,571.19
| Professional | | $1,341.96 | $2,681.07 | $3,571.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,326.61 / $1,852.11
| Facility | | $1,071.52 | $1,326.61 | $1,852.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,115.71 / $2,105.11 / $2,785.81
| Professional | | $1,115.71 | $2,105.11 | $2,785.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,107.95 / $2,017.43 / $2,430.46
| Professional | | $1,107.95 | $2,017.43 | $2,430.46 |