- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,106.56 / $1,106.56 / $8,500.00
| Facility | | $1,106.56 | $1,106.56 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,021.47 / $1,102.77 / $1,148.59
| Professional | | $1,021.47 | $1,102.77 | $1,148.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,233.16 / $2,461.42 / $2,886.15
| Professional | | $2,233.16 | $2,461.42 | $2,886.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,354.64 / $2,706.39 / $3,604.91
| Professional | | $1,354.64 | $2,706.39 | $3,604.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,106.56 / $1,465.61 / $1,989.38
| Facility | | $1,106.56 | $1,465.61 | $1,989.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,166.78 / $2,059.89 / $2,859.89
| Professional | | $1,166.78 | $2,059.89 | $2,859.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,166.78 / $2,059.89 / $2,859.89
| Professional | | $1,166.78 | $2,059.89 | $2,859.89 |