- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $1,875.52 / $3,109.00
| Facility | | $1,277.00 | $1,875.52 | $3,109.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,286.96 / $1,875.52 / $2,033.69
| Professional | | $1,286.96 | $1,875.52 | $2,033.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,391.56 / $1,841.77 / $1,841.77
| Professional | | $1,391.56 | $1,841.77 | $1,841.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,690.00 / $2,290.56 / $2,594.81
| Professional | | $1,690.00 | $2,290.56 | $2,594.81 |
- 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
- $1,263.51 / $1,512.41 / $2,865.43
| Professional | | $1,263.51 | $1,512.41 | $2,865.43 |