- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $2,049.21 / $3,601.05
| Facility | | $1,277.00 | $2,049.21 | $3,601.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,598.81 / $2,049.21 / $2,579.11
| Professional | | $1,598.81 | $2,049.21 | $2,579.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,623.31 / $2,148.50 / $2,148.50
| Professional | | $1,623.31 | $2,148.50 | $2,148.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,820.00 / $2,805.08 / $3,510.05
| Professional | | $1,820.00 | $2,805.08 | $3,510.05 |
- 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
- $1,542.27 / $2,233.67 / $3,407.61
| Professional | | $1,542.27 | $2,233.67 | $3,407.61 |