- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $2,296.71 / $3,109.00
| Facility | | $1,277.00 | $2,296.71 | $3,109.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,672.29 / $2,296.71 / $2,541.21
| Professional | | $1,672.29 | $2,296.71 | $2,541.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,720.43 / $2,277.04 / $2,277.04
| Professional | | $1,720.43 | $2,277.04 | $2,277.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,570.02 / $2,815.00 / $3,225.52
| Professional | | $1,570.02 | $2,815.00 | $3,225.52 |
- 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
- $1,612.91 / $1,936.86 / $3,335.54
| Professional | | $1,612.91 | $1,936.86 | $3,335.54 |