- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,100.00 / $1,775.00 / $2,729.00
| Facility | | $1,100.00 | $1,775.00 | $2,729.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,046.65 / $2,052.84 / $2,052.84
| Professional | | $1,046.65 | $2,052.84 | $2,052.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,103.03 / $1,511.00 / $1,782.98
| Professional | | $1,103.03 | $1,511.00 | $1,782.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,016.32 / $1,325.05 / $3,405.51
| Professional | | $1,016.32 | $1,325.05 | $3,405.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $650.00 / $1,754.00 / $5,201.00
| Facility | | $650.00 | $1,754.00 | $5,201.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $847.20 / $1,108.54 / $1,733.66
| Professional | | $847.20 | $1,108.54 | $1,733.66 |