- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,044.72 / $1,044.72 / $8,500.00
| Facility | | $1,044.72 | $1,044.72 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,006.72 / $1,046.68 / $1,079.16
| Professional | | $1,006.72 | $1,046.68 | $1,079.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,111.75 / $2,327.61 / $2,729.25
| Professional | | $2,111.75 | $2,327.61 | $2,729.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,287.48 / $2,572.21 / $3,426.19
| Professional | | $1,287.48 | $2,572.21 | $3,426.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,044.72 / $1,492.47 / $2,154.44
| Facility | | $1,044.72 | $1,492.47 | $2,154.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.76 / $1,916.54 / $2,703.98
| Professional | | $1,096.76 | $1,916.54 | $2,703.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.76 / $1,916.54 / $2,412.87
| Professional | | $1,096.76 | $1,916.54 | $2,412.87 |