- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $1,757.79 / $3,109.00
| Facility | | $1,277.00 | $1,757.79 | $3,109.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,162.36 / $1,486.19 / $1,882.96
| Professional | | $1,162.36 | $1,486.19 | $1,882.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,180.67 / $1,562.65 / $1,562.65
| Professional | | $1,180.67 | $1,562.65 | $1,562.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,458.14 / $2,048.41 / $2,544.38
| Professional | | $1,458.14 | $2,048.41 | $2,544.38 |
- 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
- $1,156.54 / $1,619.16 / $2,477.79
| Professional | | $1,156.54 | $1,619.16 | $2,477.79 |