- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,270.55 / $1,688.00 / $3,109.00
| Facility | | $1,270.55 | $1,688.00 | $3,109.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $986.32 / $1,270.55 / $1,506.83
| Professional | | $986.32 | $1,270.55 | $1,506.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,038.44 / $1,374.41 / $1,374.41
| Professional | | $1,038.44 | $1,374.41 | $1,374.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,260.46 / $1,767.42 / $2,172.67
| Professional | | $1,260.46 | $1,767.42 | $2,172.67 |
- 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
- $956.07 / $1,374.34 / $2,121.85
| Professional | | $956.07 | $1,374.34 | $2,121.85 |