- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,233.00 / $2,138.00 / $3,109.00
| Facility | | $1,233.00 | $2,138.00 | $3,109.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,801.26 / $2,137.75 / $2,735.28
| Professional | | $1,801.26 | $2,137.75 | $2,735.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,152.25 / $2,690.31 / $2,848.56
| Professional | | $2,152.25 | $2,690.31 | $2,848.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,325.00 / $2,905.13 / $3,781.00
| Professional | | $1,325.00 | $2,905.13 | $3,781.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,104.00 / $4,555.00 / $8,929.00
| Facility | | $2,104.00 | $4,555.00 | $8,929.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,304.83 / $2,153.83 / $4,160.03
| Professional | | $1,304.83 | $2,153.83 | $4,160.03 |