- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,011.32 / $1,011.32 / $8,500.00
| Facility | | $1,011.32 | $1,011.32 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $924.03 / $1,002.16 / $1,057.08
| Professional | | $924.03 | $1,002.16 | $1,057.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,017.94 / $2,219.84 / $2,602.88
| Professional | | $2,017.94 | $2,219.84 | $2,602.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,305.90 / $2,418.62 / $3,221.60
| Professional | | $1,305.90 | $2,418.62 | $3,221.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,011.32 / $1,252.99 / $1,719.24
| Facility | | $1,011.32 | $1,252.99 | $1,719.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,070.06 / $1,880.71 / $2,610.32
| Professional | | $1,070.06 | $1,880.71 | $2,610.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,070.06 / $1,855.27 / $2,182.73
| Professional | | $1,070.06 | $1,855.27 | $2,182.73 |