- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $1,773.93 / $3,109.00
| Facility | | $1,277.00 | $1,773.93 | $3,109.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,287.94 / $1,652.38 / $1,928.14
| Professional | | $1,287.94 | $1,652.38 | $1,928.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,323.31 / $1,751.45 / $1,751.45
| Professional | | $1,323.31 | $1,751.45 | $1,751.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,360.00 / $2,238.76 / $2,821.31
| Professional | | $1,360.00 | $2,238.76 | $2,821.31 |
- 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
- $1,252.67 / $1,723.49 / $2,755.30
| Professional | | $1,252.67 | $1,723.49 | $2,755.30 |