- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,083.00 / $1,678.64 / $3,109.00
| Facility | | $1,083.00 | $1,678.64 | $3,109.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $720.51 / $1,179.65 / $1,487.96
| Professional | | $720.51 | $1,179.65 | $1,487.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,420.00 / $1,879.41 / $1,879.41
| Professional | | $1,420.00 | $1,879.41 | $1,879.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,291.75 / $1,690.67 / $2,140.71
| Professional | | $1,291.75 | $1,690.67 | $2,140.71 |
- 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
- $826.60 / $1,064.25 / $1,924.44
| Professional | | $826.60 | $1,064.25 | $1,924.44 |