- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,161.09 / $1,161.09 / $8,500.00
| Facility | | $1,161.09 | $1,161.09 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,077.47 / $1,149.06 / $1,204.80
| Professional | | $1,077.47 | $1,149.06 | $1,204.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,337.50 / $2,571.37 / $3,015.06
| Professional | | $2,337.50 | $2,571.37 | $3,015.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,410.39 / $2,817.78 / $3,753.29
| Professional | | $1,410.39 | $2,817.78 | $3,753.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,161.09 / $1,535.18 / $2,004.52
| Facility | | $1,161.09 | $1,535.18 | $2,004.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,225.96 / $2,169.53 / $2,999.14
| Professional | | $1,225.96 | $2,169.53 | $2,999.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,225.96 / $2,169.53 / $2,923.16
| Professional | | $1,225.96 | $2,169.53 | $2,923.16 |