- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,188.49 / $1,688.00 / $3,109.00
| Facility | | $1,188.49 | $1,688.00 | $3,109.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $910.30 / $1,243.98 / $1,422.06
| Professional | | $910.30 | $1,243.98 | $1,422.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,097.85 / $1,372.33 / $1,453.05
| Professional | | $1,097.85 | $1,372.33 | $1,453.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,089.88 / $1,495.63 / $1,923.61
| Professional | | $1,089.88 | $1,495.63 | $1,923.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,104.00 / $4,555.00 / $8,929.00
| Facility | | $2,104.00 | $4,555.00 | $8,929.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $930.74 / $1,243.84 / $1,943.56
| Professional | | $930.74 | $1,243.84 | $1,943.56 |