- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $1,821.00 / $3,109.00
| Facility | | $1,277.00 | $1,821.00 | $3,109.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,317.65 / $1,693.09 / $2,163.36
| Professional | | $1,317.65 | $1,693.09 | $2,163.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,343.26 / $1,777.84 / $1,777.84
| Professional | | $1,343.26 | $1,777.84 | $1,777.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,555.00 / $2,322.48 / $2,899.52
| Professional | | $1,555.00 | $2,322.48 | $2,899.52 |
- 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
- $1,186.16 / $1,800.03 / $2,807.02
| Professional | | $1,186.16 | $1,800.03 | $2,807.02 |