- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,183.08 / $1,688.00 / $3,109.00
| Facility | | $1,183.08 | $1,688.00 | $3,109.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,044.21 / $1,413.46 / $1,413.46
| Professional | | $1,044.21 | $1,413.46 | $1,413.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,064.66 / $1,409.11 / $1,409.11
| Professional | | $1,064.66 | $1,409.11 | $1,409.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $953.00 / $1,601.85 / $1,985.57
| Professional | | $953.00 | $1,601.85 | $1,985.57 |
- 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
- $911.41 / $1,169.81 / $2,175.77
| Professional | | $911.41 | $1,169.81 | $2,175.77 |