- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $1,785.60 / $3,109.00
| Facility | | $1,277.00 | $1,785.60 | $3,109.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,245.65 / $1,653.59 / $1,876.36
| Professional | | $1,245.65 | $1,653.59 | $1,876.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,392.57 / $1,843.11 / $1,843.11
| Professional | | $1,392.57 | $1,843.11 | $1,843.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,590.00 / $2,163.73 / $2,616.32
| Professional | | $1,590.00 | $2,163.73 | $2,616.32 |
- 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
- $1,242.75 / $1,569.79 / $2,622.05
| Professional | | $1,242.75 | $1,569.79 | $2,622.05 |