- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $1,996.62 / $3,483.80
| Facility | | $1,277.00 | $1,996.62 | $3,483.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,516.24 / $1,950.34 / $2,289.89
| Professional | | $1,516.24 | $1,950.34 | $2,289.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,577.27 / $2,087.56 / $2,087.56
| Professional | | $1,577.27 | $2,087.56 | $2,087.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,936.17 / $2,603.09 / $3,357.18
| Professional | | $1,936.17 | $2,603.09 | $3,357.18 |
- 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
- $1,477.90 / $1,931.10 / $3,278.64
| Professional | | $1,477.90 | $1,931.10 | $3,278.64 |