- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,090.74 / $1,090.74 / $8,500.00
| Facility | | $1,090.74 | $1,090.74 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,010.28 / $1,087.33 / $1,129.85
| Professional | | $1,010.28 | $1,087.33 | $1,129.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,208.63 / $2,429.60 / $2,848.83
| Professional | | $2,208.63 | $2,429.60 | $2,848.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,338.59 / $2,674.32 / $3,562.20
| Professional | | $1,338.59 | $2,674.32 | $3,562.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,090.74 / $1,401.05 / $1,864.91
| Facility | | $1,090.74 | $1,401.05 | $1,864.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.73 / $2,048.51 / $2,820.16
| Professional | | $1,148.73 | $2,048.51 | $2,820.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.73 / $2,000.96 / $2,527.21
| Professional | | $1,148.73 | $2,000.96 | $2,527.21 |