- 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
- $1,022.35 / $1,335.56 / $1,531.69
| Professional | | $1,022.35 | $1,335.56 | $1,531.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,097.08 / $1,452.03 / $1,452.03
| Professional | | $1,097.08 | $1,452.03 | $1,452.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,150.00 / $1,694.60 / $2,073.94
| Professional | | $1,150.00 | $1,694.60 | $2,073.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $375.00 / $1,230.00 / $2,421.00
| Facility | | $375.00 | $1,230.00 | $2,421.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,005.36 / $1,378.65 / $2,293.56
| Professional | | $1,005.36 | $1,378.65 | $2,293.56 |