- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,107.58 / $1,107.58 / $8,500.00
| Facility | | $1,107.58 | $1,107.58 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,028.81 / $1,076.05 / $1,137.01
| Professional | | $1,028.81 | $1,076.05 | $1,137.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,231.64 / $2,454.91 / $2,878.52
| Professional | | $2,231.64 | $2,454.91 | $2,878.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,346.19 / $2,689.51 / $3,582.43
| Professional | | $1,346.19 | $2,689.51 | $3,582.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,107.58 / $1,399.61 / $1,882.90
| Facility | | $1,107.58 | $1,399.61 | $1,882.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,169.66 / $2,074.69 / $2,860.70
| Professional | | $1,169.66 | $2,074.69 | $2,860.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,169.66 / $2,074.69 / $2,390.51
| Professional | | $1,169.66 | $2,074.69 | $2,390.51 |