- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,071.78 / $1,688.00 / $3,109.00
| Facility | | $1,071.78 | $1,688.00 | $3,109.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $802.53 / $1,071.78 / $1,398.81
| Professional | | $802.53 | $1,071.78 | $1,398.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $938.79 / $1,173.49 / $1,242.52
| Professional | | $938.79 | $1,173.49 | $1,242.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $967.25 / $1,419.47 / $1,650.51
| Professional | | $967.25 | $1,419.47 | $1,650.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,565.00 / $2,828.00 / $6,957.00
| Facility | | $1,565.00 | $2,828.00 | $6,957.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $823.72 / $1,208.00 / $1,677.06
| Professional | | $823.72 | $1,208.00 | $1,677.06 |