- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $1,889.31 / $3,109.00
| Facility | | $1,277.00 | $1,889.31 | $3,109.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,491.00 / $1,785.93 / $2,293.42
| Professional | | $1,491.00 | $1,785.93 | $2,293.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,634.76 / $2,163.65 / $2,163.65
| Professional | | $1,634.76 | $2,163.65 | $2,163.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,484.45 / $2,542.61 / $3,056.06
| Professional | | $1,484.45 | $2,542.61 | $3,056.06 |
- 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
- $1,464.71 / $1,777.97 / $3,085.87
| Professional | | $1,464.71 | $1,777.97 | $3,085.87 |