- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,031.80 / $1,688.00 / $3,109.00
| Facility | | $1,031.80 | $1,688.00 | $3,109.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $791.61 / $1,031.80 / $1,252.02
| Professional | | $791.61 | $1,031.80 | $1,252.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $885.08 / $1,171.43 / $1,171.43
| Professional | | $885.08 | $1,171.43 | $1,171.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,029.45 / $1,432.98 / $1,582.21
| Professional | | $1,029.45 | $1,432.98 | $1,582.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,240.00 / $2,311.00 / $5,652.00
| Facility | | $1,240.00 | $2,311.00 | $5,652.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $801.47 / $1,091.23 / $1,731.56
| Professional | | $801.47 | $1,091.23 | $1,731.56 |