- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,233.00 / $1,917.64 / $3,109.00
| Facility | | $1,233.00 | $1,917.64 | $3,109.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,386.44 / $1,643.25 / $2,475.94
| Professional | | $1,386.44 | $1,643.25 | $2,475.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,661.31 / $2,076.64 / $2,198.80
| Professional | | $1,661.31 | $2,076.64 | $2,198.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,726.55 / $2,338.51 / $2,916.77
| Professional | | $1,726.55 | $2,338.51 | $2,916.77 |
- 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
- $1,428.55 / $1,929.05 / $3,194.07
| Professional | | $1,428.55 | $1,929.05 | $3,194.07 |