- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $1,688.00 / $3,109.00
| Facility | | $1,277.00 | $1,688.00 | $3,109.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,086.45 / $1,412.50 / $1,675.92
| Professional | | $1,086.45 | $1,412.50 | $1,675.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,133.67 / $1,500.44 / $1,500.44
| Professional | | $1,133.67 | $1,500.44 | $1,500.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,360.00 / $1,903.09 / $2,409.88
| Professional | | $1,360.00 | $1,903.09 | $2,409.88 |
- 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
- $985.86 / $1,507.48 / $2,353.50
| Professional | | $985.86 | $1,507.48 | $2,353.50 |