- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $2,028.00 / $3,482.30
| Facility | | $1,277.00 | $2,028.00 | $3,482.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,547.53 / $1,981.09 / $2,511.98
| Professional | | $1,547.53 | $1,981.09 | $2,511.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,570.02 / $2,077.96 / $2,077.96
| Professional | | $1,570.02 | $2,077.96 | $2,077.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,941.63 / $2,710.00 / $3,393.41
| Professional | | $1,941.63 | $2,710.00 | $3,393.41 |
- 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
- $1,514.57 / $2,104.76 / $3,295.55
| Professional | | $1,514.57 | $2,104.76 | $3,295.55 |