- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $1,771.62 / $3,109.00
| Facility | | $1,277.00 | $1,771.62 | $3,109.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,192.64 / $1,534.20 / $1,915.74
| Professional | | $1,192.64 | $1,534.20 | $1,915.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,243.20 / $1,645.42 / $1,645.42
| Professional | | $1,243.20 | $1,645.42 | $1,645.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,360.00 / $2,077.28 / $2,627.62
| Professional | | $1,360.00 | $2,077.28 | $2,627.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $375.00 / $1,230.00 / $2,421.00
| Facility | | $375.00 | $1,230.00 | $2,421.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,161.03 / $1,773.69 / $2,566.14
| Professional | | $1,161.03 | $1,773.69 | $2,566.14 |