- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $2,073.75 / $3,664.95
| Facility | | $1,277.00 | $2,073.75 | $3,664.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,616.75 / $2,073.75 / $2,677.04
| Professional | | $1,616.75 | $2,073.75 | $2,677.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,657.36 / $2,193.57 / $2,193.57
| Professional | | $1,657.36 | $2,193.57 | $2,193.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,054.44 / $2,806.87 / $3,551.17
| Professional | | $2,054.44 | $2,806.87 | $3,551.17 |
- 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
- $1,551.93 / $2,232.61 / $3,467.19
| Professional | | $1,551.93 | $2,232.61 | $3,467.19 |