- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,030.26 / $1,342.00 / $3,109.00
| Facility | | $1,030.26 | $1,342.00 | $3,109.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $810.60 / $1,030.26 / $1,175.01
| Professional | | $810.60 | $1,030.26 | $1,175.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $984.13 / $1,230.16 / $1,302.53
| Professional | | $984.13 | $1,230.16 | $1,302.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $910.33 / $1,297.65 / $1,724.72
| Professional | | $910.33 | $1,297.65 | $1,724.72 |
- 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
- $762.56 / $1,077.19 / $1,743.75
| Professional | | $762.56 | $1,077.19 | $1,743.75 |