- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,102.61 / $1,102.61 / $8,500.00
| Facility | | $1,102.61 | $1,102.61 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,018.21 / $1,101.03 / $1,145.08
| Professional | | $1,018.21 | $1,101.03 | $1,145.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,234.27 / $2,457.80 / $2,881.91
| Professional | | $2,234.27 | $2,457.80 | $2,881.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,353.79 / $2,704.70 / $3,602.67
| Professional | | $1,353.79 | $2,704.70 | $3,602.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,102.61 / $1,456.24 / $1,962.98
| Facility | | $1,102.61 | $1,456.24 | $1,962.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,161.72 / $2,063.46 / $2,850.50
| Professional | | $1,161.72 | $2,063.46 | $2,850.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,161.72 / $2,022.76 / $2,555.78
| Professional | | $1,161.72 | $2,022.76 | $2,555.78 |