- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,107.51 / $1,593.74 / $3,109.00
| Facility | | $1,107.51 | $1,593.74 | $3,109.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $849.13 / $1,175.97 / $1,240.69
| Professional | | $849.13 | $1,175.97 | $1,240.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $898.64 / $1,189.38 / $1,189.38
| Professional | | $898.64 | $1,189.38 | $1,189.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,085.57 / $1,473.31 / $1,874.92
| Professional | | $1,085.57 | $1,473.31 | $1,874.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $375.00 / $1,056.00 / $2,558.00
| Facility | | $375.00 | $1,056.00 | $2,558.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $816.94 / $1,084.42 / $1,706.82
| Professional | | $816.94 | $1,084.42 | $1,706.82 |