- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,087.85 / $1,688.00 / $3,109.00
| Facility | | $1,087.85 | $1,688.00 | $3,109.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $813.39 / $1,087.85 / $1,308.63
| Professional | | $813.39 | $1,087.85 | $1,308.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.93 / $1,236.08 / $1,236.08
| Professional | | $933.93 | $1,236.08 | $1,236.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.70 / $1,591.87 / $1,700.77
| Professional | | $1,047.70 | $1,591.87 | $1,700.77 |
- 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
- $873.07 / $1,229.32 / $1,926.76
| Professional | | $873.07 | $1,229.32 | $1,926.76 |