- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $1,923.12 / $3,375.93
| Facility | | $1,277.00 | $1,923.12 | $3,375.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,472.50 / $1,893.02 / $2,363.15
| Professional | | $1,472.50 | $1,893.02 | $2,363.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,527.48 / $2,021.66 / $2,021.66
| Professional | | $1,527.48 | $2,021.66 | $2,021.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,871.37 / $2,562.79 / $3,242.56
| Professional | | $1,871.37 | $2,562.79 | $3,242.56 |
- 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
- $1,326.50 / $2,062.37 / $3,166.70
| Professional | | $1,326.50 | $2,062.37 | $3,166.70 |