- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $1,726.26 / $3,109.00
| Facility | | $1,277.00 | $1,726.26 | $3,109.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.63 / $1,407.86 / $1,726.26
| Professional | | $1,023.63 | $1,407.86 | $1,726.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.69 / $1,538.36 / $1,628.86
| Professional | | $1,230.69 | $1,538.36 | $1,628.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,271.40 / $1,729.33 / $2,161.66
| Professional | | $1,271.40 | $1,729.33 | $2,161.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,104.00 / $4,334.00 / $8,676.00
| Facility | | $2,104.00 | $4,334.00 | $8,676.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,058.22 / $1,490.46 / $2,254.81
| Professional | | $1,058.22 | $1,490.46 | $2,254.81 |