- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $2,019.60 / $3,533.35
| Facility | | $1,277.00 | $2,019.60 | $3,533.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,544.04 / $1,983.65 / $2,473.34
| Professional | | $1,544.04 | $1,983.65 | $2,473.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,599.55 / $2,117.05 / $2,117.05
| Professional | | $1,599.55 | $2,117.05 | $2,117.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,908.66 / $2,833.51 / $3,399.11
| Professional | | $1,908.66 | $2,833.51 | $3,399.11 |
- 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
- $1,497.87 / $2,174.96 / $3,319.59
| Professional | | $1,497.87 | $2,174.96 | $3,319.59 |