- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $1,707.27 / $3,109.00
| Facility | | $1,277.00 | $1,707.27 | $3,109.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,205.23 / $1,490.18 / $1,751.28
| Professional | | $1,205.23 | $1,490.18 | $1,751.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,205.60 / $1,595.66 / $1,595.66
| Professional | | $1,205.60 | $1,595.66 | $1,595.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.18 / $2,017.56 / $2,551.75
| Professional | | $1,479.18 | $2,017.56 | $2,551.75 |
- 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
- $1,125.65 / $1,331.51 / $2,492.04
| Professional | | $1,125.65 | $1,331.51 | $2,492.04 |