- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $2,028.00 / $3,109.00
| Facility | | $1,277.00 | $2,028.00 | $3,109.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,652.36 / $1,927.87 / $2,524.75
| Professional | | $1,652.36 | $1,927.87 | $2,524.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,753.34 / $2,320.60 / $2,320.60
| Professional | | $1,753.34 | $2,320.60 | $2,320.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,598.27 / $2,745.62 / $3,286.63
| Professional | | $1,598.27 | $2,745.62 | $3,286.63 |
- 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
- $1,537.81 / $1,912.69 / $3,318.69
| Professional | | $1,537.81 | $1,912.69 | $3,318.69 |