- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $1,903.39 / $3,109.00
| Facility | | $1,277.00 | $1,903.39 | $3,109.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,452.17 / $1,962.75 / $1,962.75
| Professional | | $1,452.17 | $1,962.75 | $1,962.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,502.26 / $1,988.28 / $1,988.28
| Professional | | $1,502.26 | $1,988.28 | $1,988.28 |
- 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
- $1,262.27 / $1,591.05 / $2,810.60
| Professional | | $1,262.27 | $1,591.05 | $2,810.60 |