- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,178.52 / $1,178.52 / $8,500.00
| Facility | | $1,178.52 | $1,178.52 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,105.06 / $1,162.35 / $1,222.57
| Professional | | $1,105.06 | $1,162.35 | $1,222.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,364.46 / $2,601.02 / $3,049.83
| Professional | | $2,364.46 | $2,601.02 | $3,049.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,558.15 / $2,842.26 / $3,785.89
| Professional | | $1,558.15 | $2,842.26 | $3,785.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,178.52 / $1,670.17 / $1,987.99
| Facility | | $1,178.52 | $1,670.17 | $1,987.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,246.17 / $2,199.10 / $3,042.33
| Professional | | $1,246.17 | $2,199.10 | $3,042.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,246.17 / $2,161.98 / $2,741.57
| Professional | | $1,246.17 | $2,161.98 | $2,741.57 |