- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,173.41 / $1,666.22 / $3,109.00
| Facility | | $1,173.41 | $1,666.22 | $3,109.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $875.84 / $1,260.01 / $1,345.34
| Professional | | $875.84 | $1,260.01 | $1,345.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $939.34 / $1,243.24 / $1,243.24
| Professional | | $939.34 | $1,243.24 | $1,243.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,075.00 / $1,468.06 / $1,748.55
| Professional | | $1,075.00 | $1,468.06 | $1,748.55 |
- 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
- $846.34 / $1,000.31 / $1,795.29
| Professional | | $846.34 | $1,000.31 | $1,795.29 |