- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $1,896.86 / $3,288.05
| Facility | | $1,277.00 | $1,896.86 | $3,288.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,446.02 / $1,856.60 / $2,209.35
| Professional | | $1,446.02 | $1,856.60 | $2,209.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,487.17 / $1,968.32 / $1,968.32
| Professional | | $1,487.17 | $1,968.32 | $1,968.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,827.55 / $2,515.81 / $3,177.70
| Professional | | $1,827.55 | $2,515.81 | $3,177.70 |
- 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
- $1,390.20 / $1,718.93 / $3,103.36
| Professional | | $1,390.20 | $1,718.93 | $3,103.36 |