- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,111.23 / $1,688.00 / $3,109.00
| Facility | | $1,111.23 | $1,688.00 | $3,109.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $948.06 / $1,185.46 / $1,510.74
| Professional | | $948.06 | $1,185.46 | $1,510.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,441.93 / $1,908.43 / $1,908.43
| Professional | | $1,441.93 | $1,908.43 | $1,908.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,115.00 / $1,703.87 / $2,161.32
| Professional | | $1,115.00 | $1,703.87 | $2,161.32 |
- 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
- $849.49 / $1,082.10 / $1,937.46
| Professional | | $849.49 | $1,082.10 | $1,937.46 |