- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,331.01 / $1,331.01 / $8,500.00
| Facility | | $1,331.01 | $1,331.01 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,129.24 / $1,317.88 / $1,377.56
| Professional | | $1,129.24 | $1,317.88 | $1,377.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,682.05 / $2,950.38 / $3,459.48
| Professional | | $2,682.05 | $2,950.38 | $3,459.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,353.34 / $3,236.36 / $4,310.84
| Professional | | $1,353.34 | $3,236.36 | $4,310.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $981.03 / $1,331.01 / $2,259.92
| Facility | | $981.03 | $1,331.01 | $2,259.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,404.61 / $2,491.60 / $3,438.76
| Professional | | $1,404.61 | $2,491.60 | $3,438.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13,859.81 / $13,859.81 / $13,859.81
| Facility | | $13,859.81 | $13,859.81 | $13,859.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,404.61 / $2,441.73 / $3,357.08
| Professional | | $1,404.61 | $2,441.73 | $3,357.08 |