- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $1,876.62 / $3,109.00
| Facility | | $1,277.00 | $1,876.62 | $3,109.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,374.35 / $1,876.62 / $2,006.80
| Professional | | $1,374.35 | $1,876.62 | $2,006.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,431.20 / $1,894.23 / $1,894.23
| Professional | | $1,431.20 | $1,894.23 | $1,894.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,754.21 / $2,385.40 / $3,025.75
| Professional | | $1,754.21 | $2,385.40 | $3,025.75 |
- 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
- $1,333.79 / $1,533.09 / $2,732.35
| Professional | | $1,333.79 | $1,533.09 | $2,732.35 |