- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,241.73 / $1,688.00 / $9,034.00
| Facility | | $1,241.73 | $1,688.00 | $9,034.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $926.79 / $1,241.73 / $1,494.49
| Professional | | $926.79 | $1,241.73 | $1,494.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,062.79 / $1,328.48 / $1,406.63
| Professional | | $1,062.79 | $1,328.48 | $1,406.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,117.59 / $1,634.62 / $1,965.57
| Professional | | $1,117.59 | $1,634.62 | $1,965.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,104.00 / $4,334.00 / $8,676.00
| Facility | | $2,104.00 | $4,334.00 | $8,676.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $963.51 / $1,204.94 / $1,900.43
| Professional | | $963.51 | $1,204.94 | $1,900.43 |