- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $1,732.24 / $3,109.00
| Facility | | $1,277.00 | $1,732.24 | $3,109.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,235.10 / $1,519.60 / $1,846.00
| Professional | | $1,235.10 | $1,519.60 | $1,846.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,224.16 / $1,620.22 / $1,620.22
| Professional | | $1,224.16 | $1,620.22 | $1,620.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,507.79 / $2,057.53 / $2,605.75
| Professional | | $1,507.79 | $2,057.53 | $2,605.75 |
- 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
- $1,184.43 / $1,379.93 / $2,522.62
| Professional | | $1,184.43 | $1,379.93 | $2,522.62 |