- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $1,770.26 / $3,109.00
| Facility | | $1,277.00 | $1,770.26 | $3,109.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,179.47 / $1,507.20 / $1,899.55
| Professional | | $1,179.47 | $1,507.20 | $1,899.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,199.72 / $1,587.86 / $1,587.86
| Professional | | $1,199.72 | $1,587.86 | $1,587.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,478.59 / $2,064.42 / $2,583.62
| Professional | | $1,478.59 | $2,064.42 | $2,583.62 |
- 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
- $1,135.66 / $1,644.12 / $2,517.71
| Professional | | $1,135.66 | $1,644.12 | $2,517.71 |