- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $2,090.05 / $3,533.80
| Facility | | $1,277.00 | $2,090.05 | $3,533.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,642.98 / $2,090.05 / $2,505.85
| Professional | | $1,642.98 | $2,090.05 | $2,505.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,592.79 / $2,108.11 / $2,108.11
| Professional | | $1,592.79 | $2,108.11 | $2,108.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,972.25 / $2,898.12 / $3,445.35
| Professional | | $1,972.25 | $2,898.12 | $3,445.35 |
- 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
- $1,566.07 / $2,065.53 / $3,343.77
| Professional | | $1,566.07 | $2,065.53 | $3,343.77 |