- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,019.38 / $1,019.38 / $8,500.00
| Facility | | $1,019.38 | $1,019.38 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $907.15 / $1,019.38 / $1,089.36
| Professional | | $907.15 | $1,019.38 | $1,089.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,102.10 / $2,332.12 / $2,743.67
| Professional | | $2,102.10 | $2,332.12 | $2,743.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,388.40 / $2,598.37 / $3,461.03
| Professional | | $1,388.40 | $2,598.37 | $3,461.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,019.38 / $1,342.60 / $1,804.79
| Facility | | $1,019.38 | $1,342.60 | $1,804.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,067.89 / $1,870.05 / $2,640.74
| Professional | | $1,067.89 | $1,870.05 | $2,640.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,067.89 / $1,870.05 / $2,349.36
| Professional | | $1,067.89 | $1,870.05 | $2,349.36 |