- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,076.49 / $1,076.49 / $8,500.00
| Facility | | $1,076.49 | $1,076.49 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $995.40 / $1,074.23 / $1,118.13
| Professional | | $995.40 | $1,074.23 | $1,118.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,174.10 / $2,396.32 / $2,809.82
| Professional | | $2,174.10 | $2,396.32 | $2,809.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,319.16 / $2,635.50 / $3,510.49
| Professional | | $1,319.16 | $2,635.50 | $3,510.49 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,076.49 / $1,467.31 / $1,931.26
| Facility | | $1,076.49 | $1,467.31 | $1,931.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,134.30 / $2,003.84 / $2,782.78
| Professional | | $1,134.30 | $2,003.84 | $2,782.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,134.30 / $1,974.82 / $2,734.73
| Professional | | $1,134.30 | $1,974.82 | $2,734.73 |