- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,191.58 / $1,688.00 / $3,109.00
| Facility | | $1,191.58 | $1,688.00 | $3,109.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $886.24 / $1,277.82 / $1,390.17
| Professional | | $886.24 | $1,277.82 | $1,390.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $952.26 / $1,260.33 / $1,260.33
| Professional | | $952.26 | $1,260.33 | $1,260.33 |
- 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
- $856.93 / $1,008.27 / $1,821.16
| Professional | | $856.93 | $1,008.27 | $1,821.16 |