- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,029.09 / $1,029.09 / $8,500.00
| Facility | | $1,029.09 | $1,029.09 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $940.66 / $1,029.09 / $1,029.35
| Professional | | $940.66 | $1,029.09 | $1,029.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,001.51 / $2,206.09 / $2,586.77
| Professional | | $2,001.51 | $2,206.09 | $2,586.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,260.02 / $2,517.35 / $3,353.12
| Professional | | $1,260.02 | $2,517.35 | $3,353.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,029.09 / $1,354.19 / $1,813.48
| Facility | | $1,029.09 | $1,354.19 | $1,813.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,053.82 / $1,862.86 / $2,681.51
| Professional | | $1,053.82 | $1,862.86 | $2,681.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,053.82 / $1,862.86 / $2,318.40
| Professional | | $1,053.82 | $1,862.86 | $2,318.40 |