- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,055.43 / $1,055.43 / $8,500.00
| Facility | | $1,055.43 | $1,055.43 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $893.34 / $1,052.26 / $1,092.57
| Professional | | $893.34 | $1,052.26 | $1,092.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,132.76 / $2,350.76 / $2,756.39
| Professional | | $2,132.76 | $2,350.76 | $2,756.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,077.50 / $2,588.23 / $3,447.54
| Professional | | $1,077.50 | $2,588.23 | $3,447.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $763.25 / $1,055.43 / $1,804.81
| Facility | | $763.25 | $1,055.43 | $1,804.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,111.56 / $1,984.79 / $2,729.01
| Professional | | $1,111.56 | $1,984.79 | $2,729.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,111.56 / $1,936.19 / $2,445.42
| Professional | | $1,111.56 | $1,936.19 | $2,445.42 |