- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $2,028.00 / $3,216.70
| Facility | | $1,277.00 | $2,028.00 | $3,216.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,496.11 / $1,828.54 / $2,359.65
| Professional | | $1,496.11 | $1,828.54 | $2,359.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,450.09 / $1,919.24 / $1,919.24
| Professional | | $1,450.09 | $1,919.24 | $1,919.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,788.11 / $2,546.85 / $3,132.80
| Professional | | $1,788.11 | $2,546.85 | $3,132.80 |
- 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
- $1,409.12 / $1,891.50 / $3,045.31
| Professional | | $1,409.12 | $1,891.50 | $3,045.31 |