- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,083.00 / $1,342.00 / $3,109.00
| Facility | | $1,083.00 | $1,342.00 | $3,109.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $866.62 / $1,150.79 / $1,294.86
| Professional | | $866.62 | $1,150.79 | $1,294.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,018.58 / $1,273.22 / $1,348.12
| Professional | | $1,018.58 | $1,273.22 | $1,348.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.92 / $1,454.76 / $1,785.20
| Professional | | $1,023.92 | $1,454.76 | $1,785.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,741.00 / $7,019.00 / $12,000.00
| Facility | | $3,741.00 | $7,019.00 | $12,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $869.73 / $1,201.05 / $1,804.81
| Professional | | $869.73 | $1,201.05 | $1,804.81 |