- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $1,983.80 / $3,451.60
| Facility | | $1,277.00 | $1,983.80 | $3,451.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,515.95 / $1,950.74 / $2,307.64
| Professional | | $1,515.95 | $1,950.74 | $2,307.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,557.96 / $2,062.01 / $2,062.01
| Professional | | $1,557.96 | $2,062.01 | $2,062.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,929.35 / $2,606.26 / $3,330.95
| Professional | | $1,929.35 | $2,606.26 | $3,330.95 |
- 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
- $1,475.17 / $1,956.88 / $3,253.02
| Professional | | $1,475.17 | $1,956.88 | $3,253.02 |