- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $1,746.51 / $3,109.00
| Facility | | $1,277.00 | $1,746.51 | $3,109.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,181.68 / $1,474.40 / $1,874.37
| Professional | | $1,181.68 | $1,474.40 | $1,874.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,171.68 / $1,550.75 / $1,550.75
| Professional | | $1,171.68 | $1,550.75 | $1,550.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,447.15 / $2,085.54 / $2,524.39
| Professional | | $1,447.15 | $2,085.54 | $2,524.39 |
- 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
- $1,147.45 / $1,489.70 / $2,443.86
| Professional | | $1,147.45 | $1,489.70 | $2,443.86 |