- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,036.41 / $1,036.41 / $8,500.00
| Facility | | $1,036.41 | $1,036.41 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $974.60 / $1,036.41 / $1,036.41
| Professional | | $974.60 | $1,036.41 | $1,036.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,990.57 / $2,165.21 / $2,595.62
| Professional | | $1,990.57 | $2,165.21 | $2,595.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,248.79 / $2,417.94 / $3,122.43
| Professional | | $1,248.79 | $2,417.94 | $3,122.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,036.41 / $1,448.01 / $3,109.23
| Facility | | $1,036.41 | $1,448.01 | $3,109.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,076.55 / $1,946.68 / $2,685.58
| Professional | | $1,076.55 | $1,946.68 | $2,685.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,140.38 / $2,239.21 / $2,685.58
| Professional | | $1,140.38 | $2,239.21 | $2,685.58 |