- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $2,028.00 / $3,565.27
| Facility | | $1,277.00 | $2,028.00 | $3,565.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,557.73 / $2,014.57 / $2,406.62
| Professional | | $1,557.73 | $2,014.57 | $2,406.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,609.00 / $2,129.56 / $2,129.56
| Professional | | $1,609.00 | $2,129.56 | $2,129.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,985.12 / $2,720.38 / $3,438.59
| Professional | | $1,985.12 | $2,720.38 | $3,438.59 |
- 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
- $1,526.24 / $2,031.20 / $3,358.15
| Professional | | $1,526.24 | $2,031.20 | $3,358.15 |