- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,210.67 / $1,688.00 / $3,109.00
| Facility | | $1,210.67 | $1,688.00 | $3,109.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $906.72 / $1,210.67 / $1,470.15
| Professional | | $906.72 | $1,210.67 | $1,470.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,043.11 / $1,380.60 / $1,380.60
| Professional | | $1,043.11 | $1,380.60 | $1,380.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,225.17 / $1,770.07 / $2,410.00
| Professional | | $1,225.17 | $1,770.07 | $2,410.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,240.00 / $2,314.00 / $5,652.00
| Facility | | $1,240.00 | $2,314.00 | $5,652.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $969.08 / $1,372.65 / $2,036.36
| Professional | | $969.08 | $1,372.65 | $2,036.36 |