- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $2,028.00 / $3,368.85
| Facility | | $1,277.00 | $2,028.00 | $3,368.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,561.85 / $2,002.38 / $2,445.83
| Professional | | $1,561.85 | $2,002.38 | $2,445.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,518.11 / $2,009.26 / $2,009.26
| Professional | | $1,518.11 | $2,009.26 | $2,009.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,993.06 / $2,718.99 / $3,282.65
| Professional | | $1,993.06 | $2,718.99 | $3,282.65 |
- 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
- $1,492.12 / $2,088.96 / $3,187.46
| Professional | | $1,492.12 | $2,088.96 | $3,187.46 |