- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $1,778.58 / $3,109.00
| Facility | | $1,277.00 | $1,778.58 | $3,109.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,289.77 / $1,462.34 / $1,835.89
| Professional | | $1,289.77 | $1,462.34 | $1,835.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,158.32 / $1,533.07 / $1,533.07
| Professional | | $1,158.32 | $1,533.07 | $1,533.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,436.00 / $2,027.25 / $2,502.12
| Professional | | $1,436.00 | $2,027.25 | $2,502.12 |
- 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
- $1,122.26 / $1,503.06 / $2,431.65
| Professional | | $1,122.26 | $1,503.06 | $2,431.65 |