- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,056.43 / $1,056.43 / $8,500.00
| Facility | | $1,056.43 | $1,056.43 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $990.63 / $1,056.43 / $1,056.43
| Professional | | $990.63 | $1,056.43 | $1,056.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,088.37 / $2,286.41 / $2,740.90
| Professional | | $2,088.37 | $2,286.41 | $2,740.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,327.02 / $2,545.38 / $3,286.99
| Professional | | $1,327.02 | $2,545.38 | $3,286.99 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,056.43 / $1,520.82 / $3,169.29
| Facility | | $1,056.43 | $1,520.82 | $3,169.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.76 / $1,938.02 / $2,740.14
| Professional | | $1,096.76 | $1,938.02 | $2,740.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,123.83 / $2,043.34 / $2,740.14
| Professional | | $1,123.83 | $2,043.34 | $2,740.14 |