- 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
- $1,027.71 / $1,315.66 / $1,589.46
| Professional | | $1,027.71 | $1,315.66 | $1,589.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $982.57 / $1,300.46 / $1,300.46
| Professional | | $982.57 | $1,300.46 | $1,300.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,294.76 / $1,789.08 / $2,119.63
| Professional | | $1,294.76 | $1,789.08 | $2,119.63 |
- 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
- $963.47 / $1,345.09 / $2,061.40
| Professional | | $963.47 | $1,345.09 | $2,061.40 |