- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $2,151.61 / $3,836.52
| Facility | | $1,277.00 | $2,151.61 | $3,836.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,674.84 / $2,151.61 / $2,581.79
| Professional | | $1,674.84 | $2,151.61 | $2,581.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,736.39 / $2,298.17 / $2,298.17
| Professional | | $1,736.39 | $2,298.17 | $2,298.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,655.00 / $2,881.51 / $3,692.89
| Professional | | $1,655.00 | $2,881.51 | $3,692.89 |
- 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
- $1,626.10 / $2,307.92 / $3,627.40
| Professional | | $1,626.10 | $2,307.92 | $3,627.40 |