- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,001.11 / $1,001.11 / $8,500.00
| Facility | | $1,001.11 | $1,001.11 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $867.43 / $968.51 / $1,361.04
| Professional | | $867.43 | $968.51 | $1,361.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,970.62 / $2,130.73 / $2,550.21
| Professional | | $1,970.62 | $2,130.73 | $2,550.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,475.87 / $2,390.17 / $3,086.56
| Professional | | $1,475.87 | $2,390.17 | $3,086.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,001.11 / $1,238.46 / $1,701.89
| Facility | | $1,001.11 | $1,238.46 | $1,701.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,037.67 / $1,777.72 / $7,447.60
| Professional | | $1,037.67 | $1,777.72 | $7,447.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,037.67 / $1,777.72 / $2,722.30
| Professional | | $1,037.67 | $1,777.72 | $2,722.30 |