- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $1,688.00 / $3,109.00
| Facility | | $1,277.00 | $1,688.00 | $3,109.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,050.16 / $1,336.18 / $1,665.30
| Professional | | $1,050.16 | $1,336.18 | $1,665.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,058.77 / $1,401.31 / $1,401.31
| Professional | | $1,058.77 | $1,401.31 | $1,401.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.00 / $1,716.09 / $2,287.21
| Professional | | $1,230.00 | $1,716.09 | $2,287.21 |
- 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
- $1,017.23 / $1,261.58 / $2,222.66
| Professional | | $1,017.23 | $1,261.58 | $2,222.66 |