- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,031.28 / $1,635.40 / $3,109.00
| Facility | | $1,031.28 | $1,635.40 | $3,109.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $860.32 / $1,031.28 / $1,193.68
| Professional | | $860.32 | $1,031.28 | $1,193.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $929.44 / $1,230.14 / $1,230.14
| Professional | | $929.44 | $1,230.14 | $1,230.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,013.65 / $1,360.70 / $1,591.14
| Professional | | $1,013.65 | $1,360.70 | $1,591.14 |
- 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
- $814.55 / $1,017.77 / $1,752.01
| Professional | | $814.55 | $1,017.77 | $1,752.01 |