- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $1,728.28 / $9,477.00
| Facility | | $1,277.00 | $1,728.28 | $9,477.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,158.40 / $1,593.66 / $1,728.28
| Professional | | $1,158.40 | $1,593.66 | $1,728.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,197.80 / $1,585.32 / $1,585.32
| Professional | | $1,197.80 | $1,585.32 | $1,585.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,050.00 / $1,997.36 / $2,537.42
| Professional | | $1,050.00 | $1,997.36 | $2,537.42 |
- 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
- $1,110.29 / $1,334.25 / $2,309.91
| Professional | | $1,110.29 | $1,334.25 | $2,309.91 |