- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $1,814.66 / $3,109.00
| Facility | | $1,277.00 | $1,814.66 | $3,109.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,164.02 / $1,491.68 / $1,874.09
| Professional | | $1,164.02 | $1,491.68 | $1,874.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,181.34 / $1,563.55 / $1,563.55
| Professional | | $1,181.34 | $1,563.55 | $1,563.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,460.07 / $2,067.11 / $2,551.14
| Professional | | $1,460.07 | $2,067.11 | $2,551.14 |
- 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
- $1,043.65 / $1,535.91 / $2,491.46
| Professional | | $1,043.65 | $1,535.91 | $2,491.46 |