- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $2,028.00 / $3,565.95
| Facility | | $1,277.00 | $2,028.00 | $3,565.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,559.39 / $2,015.34 / $2,404.53
| Professional | | $1,559.39 | $2,015.34 | $2,404.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,609.66 / $2,130.44 / $2,130.44
| Professional | | $1,609.66 | $2,130.44 | $2,130.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,992.20 / $2,728.72 / $3,440.92
| Professional | | $1,992.20 | $2,728.72 | $3,440.92 |
- 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
- $1,518.53 / $2,194.14 / $3,360.41
| Professional | | $1,518.53 | $2,194.14 | $3,360.41 |