- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $1,688.51 / $3,109.00
| Facility | | $1,277.00 | $1,688.51 | $3,109.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,160.02 / $1,688.51 / $1,825.10
| Professional | | $1,160.02 | $1,688.51 | $1,825.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,262.58 / $1,671.07 / $1,671.07
| Professional | | $1,262.58 | $1,671.07 | $1,671.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,550.77 / $2,025.00 / $2,350.16
| Professional | | $1,550.77 | $2,025.00 | $2,350.16 |
- 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
- $1,142.74 / $1,757.76 / $2,409.07
| Professional | | $1,142.74 | $1,757.76 | $2,409.07 |