- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,072.81 / $1,688.00 / $3,109.00
| Facility | | $1,072.81 | $1,688.00 | $3,109.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $796.48 / $1,072.81 / $1,263.59
| Professional | | $796.48 | $1,072.81 | $1,263.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $948.93 / $1,186.16 / $1,255.93
| Professional | | $948.93 | $1,186.16 | $1,255.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,209.00 / $4,576.00 / $8,929.00
| Facility | | $2,209.00 | $4,576.00 | $8,929.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $811.64 / $1,027.86 / $1,673.64
| Professional | | $811.64 | $1,027.86 | $1,673.64 |