- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,027.68 / $1,295.00 / $3,804.00
| Facility | | $1,027.68 | $1,295.00 | $3,804.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $784.19 / $1,092.47 / $1,200.13
| Professional | | $784.19 | $1,092.47 | $1,200.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $825.42 / $1,092.47 / $1,092.47
| Professional | | $825.42 | $1,092.47 | $1,092.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,007.27 / $1,467.01 / $1,740.60
| Professional | | $1,007.27 | $1,467.01 | $1,740.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,240.00 / $2,311.00 / $5,652.00
| Facility | | $1,240.00 | $2,311.00 | $5,652.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $770.99 / $909.23 / $1,584.54
| Professional | | $770.99 | $909.23 | $1,584.54 |