- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $1,758.52 / $3,109.00
| Facility | | $1,277.00 | $1,758.52 | $3,109.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.59 / $1,583.86 / $1,884.79
| Professional | | $1,230.59 | $1,583.86 | $1,884.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,281.85 / $1,696.58 / $1,696.58
| Professional | | $1,281.85 | $1,696.58 | $1,696.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,571.52 / $2,277.92 / $2,735.00
| Professional | | $1,571.52 | $2,277.92 | $2,735.00 |
- 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
- $1,195.32 / $1,773.58 / $2,675.03
| Professional | | $1,195.32 | $1,773.58 | $2,675.03 |