- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,015.96 / $1,015.96 / $8,500.00
| Facility | | $1,015.96 | $1,015.96 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $938.57 / $1,015.16 / $1,054.43
| Professional | | $938.57 | $1,015.16 | $1,054.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,013.74 / $2,256.42 / $2,654.62
| Professional | | $2,013.74 | $2,256.42 | $2,654.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,317.31 / $2,492.88 / $3,320.52
| Professional | | $1,317.31 | $2,492.88 | $3,320.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,015.96 / $1,381.39 / $1,738.04
| Facility | | $1,015.96 | $1,381.39 | $1,738.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,070.42 / $1,883.23 / $2,626.56
| Professional | | $1,070.42 | $1,883.23 | $2,626.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,070.42 / $1,894.64 / $2,586.16
| Professional | | $1,070.42 | $1,894.64 | $2,586.16 |