- 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
- $1,038.68 / $1,348.03 / $1,557.14
| Professional | | $1,038.68 | $1,348.03 | $1,557.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,081.57 / $1,431.50 / $1,431.50
| Professional | | $1,081.57 | $1,431.50 | $1,431.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,333.38 / $1,844.09 / $2,302.17
| Professional | | $1,333.38 | $1,844.09 | $2,302.17 |
- 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
- $1,046.44 / $1,394.56 / $2,248.31
| Professional | | $1,046.44 | $1,394.56 | $2,248.31 |