- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $1,796.10 / $3,109.00
| Facility | | $1,277.00 | $1,796.10 | $3,109.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,214.54 / $1,670.23 / $1,886.15
| Professional | | $1,214.54 | $1,670.23 | $1,886.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,356.41 / $1,795.25 / $1,795.25
| Professional | | $1,356.41 | $1,795.25 | $1,795.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,653.52 / $2,267.98 / $2,868.46
| Professional | | $1,653.52 | $2,267.98 | $2,868.46 |
- 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
- $1,262.69 / $1,712.16 / $2,801.34
| Professional | | $1,262.69 | $1,712.16 | $2,801.34 |