- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $1,861.92 / $3,109.00
| Facility | | $1,277.00 | $1,861.92 | $3,109.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,347.61 / $1,861.92 / $2,063.48
| Professional | | $1,347.61 | $1,861.92 | $2,063.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,398.32 / $1,850.72 / $1,850.72
| Professional | | $1,398.32 | $1,850.72 | $1,850.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,272.92 / $2,238.05 / $2,619.44
| Professional | | $1,272.92 | $2,238.05 | $2,619.44 |
- 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
- $1,343.98 / $1,548.22 / $2,703.79
| Professional | | $1,343.98 | $1,548.22 | $2,703.79 |