- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,023.85 / $1,023.85 / $8,500.00
| Facility | | $1,023.85 | $1,023.85 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $906.90 / $1,007.17 / $1,071.02
| Professional | | $906.90 | $1,007.17 | $1,071.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,046.21 / $2,250.94 / $2,639.35
| Professional | | $2,046.21 | $2,250.94 | $2,639.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,222.43 / $2,442.25 / $3,253.08
| Professional | | $1,222.43 | $2,442.25 | $3,253.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,023.85 / $1,227.92 / $1,712.38
| Facility | | $1,023.85 | $1,227.92 | $1,712.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,086.30 / $1,907.81 / $2,640.85
| Professional | | $1,086.30 | $1,907.81 | $2,640.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,086.30 / $1,907.81 / $2,389.86
| Professional | | $1,086.30 | $1,907.81 | $2,389.86 |