- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,089.67 / $1,688.00 / $3,109.00
| Facility | | $1,089.67 | $1,688.00 | $3,109.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $871.26 / $1,120.74 / $1,394.87
| Professional | | $871.26 | $1,120.74 | $1,394.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $902.03 / $1,193.85 / $1,193.85
| Professional | | $902.03 | $1,193.85 | $1,193.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,111.32 / $1,517.63 / $1,917.16
| Professional | | $1,111.32 | $1,517.63 | $1,917.16 |
- 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
- $844.92 / $1,216.63 / $1,872.31
| Professional | | $844.92 | $1,216.63 | $1,872.31 |