- 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
- $1,252.65 / $1,591.44 / $2,021.94
| Professional | | $1,252.65 | $1,591.44 | $2,021.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,263.32 / $1,672.05 / $1,672.05
| Professional | | $1,263.32 | $1,672.05 | $1,672.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,561.57 / $2,181.64 / $2,724.48
| Professional | | $1,561.57 | $2,181.64 | $2,724.48 |
- 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
- $1,221.33 / $1,705.28 / $2,660.74
| Professional | | $1,221.33 | $1,705.28 | $2,660.74 |