- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,001.57 / $1,001.57 / $8,500.00
| Facility | | $1,001.57 | $1,001.57 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.61 / $933.61 / $1,670.33
| Professional | | $933.61 | $933.61 | $1,670.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,950.68 / $2,106.17 / $2,524.41
| Professional | | $1,950.68 | $2,106.17 | $2,524.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,454.19 / $2,355.05 / $3,041.20
| Professional | | $1,454.19 | $2,355.05 | $3,041.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,001.57 / $1,225.94 / $1,702.67
| Facility | | $1,001.57 | $1,225.94 | $1,702.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,048.40 / $1,698.31 / $7,507.56
| Professional | | $1,048.40 | $1,698.31 | $7,507.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $949.33 / $1,548.90 / $2,594.27
| Professional | | $949.33 | $1,548.90 | $2,594.27 |