- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,027.26 / $1,027.26 / $8,500.00
| Facility | | $1,027.26 | $1,027.26 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $955.16 / $1,026.01 / $1,056.15
| Professional | | $955.16 | $1,026.01 | $1,056.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,072.52 / $2,279.88 / $2,673.27
| Professional | | $2,072.52 | $2,279.88 | $2,673.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,262.55 / $2,522.42 / $3,359.87
| Professional | | $1,262.55 | $2,522.42 | $3,359.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,027.26 / $1,274.45 / $1,755.90
| Facility | | $1,027.26 | $1,274.45 | $1,755.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,078.00 / $1,918.93 / $2,658.65
| Professional | | $1,078.00 | $1,918.93 | $2,658.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,078.00 / $1,884.51 / $2,371.60
| Professional | | $1,078.00 | $1,884.51 | $2,371.60 |