- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $1,795.76 / $3,109.00
| Facility | | $1,277.00 | $1,795.76 | $3,109.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,210.77 / $1,545.23 / $1,944.29
| Professional | | $1,210.77 | $1,545.23 | $1,944.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,223.56 / $1,619.42 / $1,619.42
| Professional | | $1,223.56 | $1,619.42 | $1,619.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.73 / $2,073.36 / $2,644.57
| Professional | | $1,513.73 | $2,073.36 | $2,644.57 |
- 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
- $1,202.08 / $1,472.95 / $2,560.21
| Professional | | $1,202.08 | $1,472.95 | $2,560.21 |