- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,038.38 / $1,038.38 / $8,500.00
| Facility | | $1,038.38 | $1,038.38 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $817.01 / $1,016.11 / $1,139.58
| Professional | | $817.01 | $1,016.11 | $1,139.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,065.82 / $2,276.98 / $2,669.88
| Professional | | $2,065.82 | $2,276.98 | $2,669.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,260.02 / $2,517.35 / $3,353.12
| Professional | | $1,260.02 | $2,517.35 | $3,353.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,038.38 / $1,462.73 / $1,978.98
| Facility | | $1,038.38 | $1,462.73 | $1,978.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,085.21 / $1,904.91 / $2,687.79
| Professional | | $1,085.21 | $1,904.91 | $2,687.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,978.00 / $1,978.00 / $1,978.00
| Facility | | $1,978.00 | $1,978.00 | $1,978.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,085.21 / $1,901.68 / $2,241.14
| Professional | | $1,085.21 | $1,901.68 | $2,241.14 |