- 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
- $1,077.28 / $1,686.41 / $1,686.41
| Professional | | $1,077.28 | $1,686.41 | $1,686.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,265.09 / $1,674.40 / $1,674.40
| Professional | | $1,265.09 | $1,674.40 | $1,674.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,075.00 / $1,898.54 / $2,307.71
| Professional | | $1,075.00 | $1,898.54 | $2,307.71 |
- 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
- $1,063.83 / $1,327.48 / $2,344.42
| Professional | | $1,063.83 | $1,327.48 | $2,344.42 |