- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,046.42 / $1,046.42 / $8,500.00
| Facility | | $1,046.42 | $1,046.42 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $960.39 / $1,046.05 / $1,086.03
| Professional | | $960.39 | $1,046.05 | $1,086.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,121.83 / $2,334.12 / $2,736.89
| Professional | | $2,121.83 | $2,334.12 | $2,736.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,314.77 / $2,570.52 / $3,423.94
| Professional | | $1,314.77 | $2,570.52 | $3,423.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,046.42 / $1,402.46 / $1,791.99
| Facility | | $1,046.42 | $1,402.46 | $1,791.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,102.18 / $1,957.03 / $2,705.60
| Professional | | $1,102.18 | $1,957.03 | $2,705.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,102.18 / $1,919.66 / $2,424.80
| Professional | | $1,102.18 | $1,919.66 | $2,424.80 |