- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,002.86 / $1,002.86 / $8,500.00
| Facility | | $1,002.86 | $1,002.86 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $929.28 / $1,002.86 / $1,031.43
| Professional | | $929.28 | $1,002.86 | $1,031.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,011.35 / $2,216.94 / $2,599.48
| Professional | | $2,011.35 | $2,216.94 | $2,599.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,209.33 / $2,416.09 / $3,218.23
| Professional | | $1,209.33 | $2,416.09 | $3,218.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,002.86 / $1,239.28 / $1,704.86
| Facility | | $1,002.86 | $1,239.28 | $1,704.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,054.90 / $1,865.93 / $2,593.25
| Professional | | $1,054.90 | $1,865.93 | $2,593.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,054.90 / $1,839.75 / $2,320.78
| Professional | | $1,054.90 | $1,839.75 | $2,320.78 |