- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,077.07 / $1,077.07 / $8,500.00
| Facility | | $1,077.07 | $1,077.07 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,077.07 / $1,094.99 / $1,160.38
| Professional | | $1,077.07 | $1,094.99 | $1,160.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,164.26 / $2,385.46 / $2,797.10
| Professional | | $2,164.26 | $2,385.46 | $2,797.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,332.25 / $2,661.66 / $3,545.34
| Professional | | $1,332.25 | $2,661.66 | $3,545.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,077.07 / $1,494.13 / $1,849.63
| Facility | | $1,077.07 | $1,494.13 | $1,849.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,147.54 / $2,130.46 / $2,791.54
| Professional | | $1,147.54 | $2,130.46 | $2,791.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,121.30 / $2,037.03 / $2,466.86
| Professional | | $1,121.30 | $2,037.03 | $2,466.86 |