- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,108.74 / $1,108.74 / $8,500.00
| Facility | | $1,108.74 | $1,108.74 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,022.24 / $1,104.64 / $1,148.80
| Professional | | $1,022.24 | $1,104.64 | $1,148.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,243.46 / $2,467.92 / $2,893.79
| Professional | | $2,243.46 | $2,467.92 | $2,893.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,359.28 / $2,715.67 / $3,617.28
| Professional | | $1,359.28 | $2,715.67 | $3,617.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,108.74 / $1,379.58 / $1,902.11
| Facility | | $1,108.74 | $1,379.58 | $1,902.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,168.22 / $2,184.37 / $2,866.30
| Professional | | $1,168.22 | $2,184.37 | $2,866.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,168.22 / $2,067.75 / $2,570.08
| Professional | | $1,168.22 | $2,067.75 | $2,570.08 |