- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,181.00 / $1,957.13 / $9,477.00
| Facility | | $1,181.00 | $1,957.13 | $9,477.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,520.04 / $1,957.13 / $2,328.98
| Professional | | $1,520.04 | $1,957.13 | $2,328.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,314.26 / $1,739.46 / $1,739.46
| Professional | | $1,314.26 | $1,739.46 | $1,739.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,900.07 / $2,631.85 / $3,048.69
| Professional | | $1,900.07 | $2,631.85 | $3,048.69 |
- 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
- $1,247.44 / $2,045.54 / $2,777.15
| Professional | | $1,247.44 | $2,045.54 | $2,777.15 |