- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $2,027.01 / $3,482.75
| Facility | | $1,277.00 | $2,027.01 | $3,482.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,533.83 / $1,969.77 / $2,437.92
| Professional | | $1,533.83 | $1,969.77 | $2,437.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,572.32 / $2,081.02 / $2,081.02
| Professional | | $1,572.32 | $2,081.02 | $2,081.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,950.57 / $2,695.37 / $3,361.09
| Professional | | $1,950.57 | $2,695.37 | $3,361.09 |
- 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
- $1,488.97 / $1,903.55 / $3,282.46
| Professional | | $1,488.97 | $1,903.55 | $3,282.46 |