- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,441.84 / $1,904.00 / $9,477.00
| Facility | | $1,441.84 | $1,904.00 | $9,477.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,087.30 / $1,441.84 / $1,743.14
| Professional | | $1,087.30 | $1,441.84 | $1,743.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,242.66 / $1,644.70 / $1,644.70
| Professional | | $1,242.66 | $1,644.70 | $1,644.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,436.30 / $2,102.64 / $2,198.86
| Professional | | $1,436.30 | $2,102.64 | $2,198.86 |
- 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
- $1,141.01 / $1,469.10 / $2,393.29
| Professional | | $1,141.01 | $1,469.10 | $2,393.29 |