- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,200.24 / $1,688.00 / $3,109.00
| Facility | | $1,200.24 | $1,688.00 | $3,109.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $894.71 / $1,285.83 / $1,385.93
| Professional | | $894.71 | $1,285.83 | $1,385.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $952.62 / $1,260.82 / $1,260.82
| Professional | | $952.62 | $1,260.82 | $1,260.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,100.00 / $1,485.44 / $1,796.54
| Professional | | $1,100.00 | $1,485.44 | $1,796.54 |
- 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
- $865.04 / $1,029.30 / $1,972.74
| Professional | | $865.04 | $1,029.30 | $1,972.74 |