- 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
- $1,403.46 / $1,602.84 / $2,047.04
| Professional | | $1,403.46 | $1,602.84 | $2,047.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,272.71 / $1,684.47 / $1,684.47
| Professional | | $1,272.71 | $1,684.47 | $1,684.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,390.00 / $2,211.17 / $2,744.48
| Professional | | $1,390.00 | $2,211.17 | $2,744.48 |
- 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
- $1,247.49 / $1,720.21 / $2,680.27
| Professional | | $1,247.49 | $1,720.21 | $2,680.27 |