- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $2,028.00 / $3,574.85
| Facility | | $1,277.00 | $2,028.00 | $3,574.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,562.54 / $2,006.92 / $2,395.07
| Professional | | $1,562.54 | $2,006.92 | $2,395.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,618.14 / $2,141.66 / $2,141.66
| Professional | | $1,618.14 | $2,141.66 | $2,141.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,985.90 / $2,716.75 / $3,438.20
| Professional | | $1,985.90 | $2,716.75 | $3,438.20 |
- 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
- $1,514.32 / $2,208.09 / $3,357.77
| Professional | | $1,514.32 | $2,208.09 | $3,357.77 |