- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,010.68 / $1,376.73 / $3,109.00
| Facility | | $1,010.68 | $1,376.73 | $3,109.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $748.17 / $1,053.29 / $1,126.98
| Professional | | $748.17 | $1,053.29 | $1,126.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.80 / $1,028.11 / $1,028.11
| Professional | | $776.80 | $1,028.11 | $1,028.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $866.00 / $1,203.33 / $1,445.44
| Professional | | $866.00 | $1,203.33 | $1,445.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,240.00 / $2,931.00 / $5,626.00
| Facility | | $1,240.00 | $2,931.00 | $5,626.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $700.60 / $839.27 / $1,590.08
| Professional | | $700.60 | $839.27 | $1,590.08 |