- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $1,688.00 / $3,109.00
| Facility | | $1,277.00 | $1,688.00 | $3,109.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $957.24 / $1,397.35 / $1,520.77
| Professional | | $957.24 | $1,397.35 | $1,520.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,039.01 / $1,375.16 / $1,375.16
| Professional | | $1,039.01 | $1,375.16 | $1,375.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,280.00 / $1,623.64 / $1,936.58
| Professional | | $1,280.00 | $1,623.64 | $1,936.58 |
- 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
- $938.05 / $1,107.17 / $1,991.09
| Professional | | $938.05 | $1,107.17 | $1,991.09 |