- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,060.45 / $1,060.45 / $8,500.00
| Facility | | $1,060.45 | $1,060.45 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $971.15 / $1,058.08 / $1,100.73
| Professional | | $971.15 | $1,058.08 | $1,100.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,120.29 / $2,352.31 / $2,767.42
| Professional | | $2,120.29 | $2,352.31 | $2,767.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,363.96 / $2,597.52 / $3,459.91
| Professional | | $1,363.96 | $2,597.52 | $3,459.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,060.45 / $1,413.57 / $1,811.25
| Facility | | $1,060.45 | $1,413.57 | $1,811.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,117.69 / $1,945.40 / $2,741.18
| Professional | | $1,117.69 | $1,945.40 | $2,741.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,117.69 / $1,945.40 / $2,741.18
| Professional | | $1,117.69 | $1,945.40 | $2,741.18 |