- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $2,150.77 / $3,607.48
| Facility | | $1,277.00 | $2,150.77 | $3,607.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,669.10 / $2,128.53 / $2,396.71
| Professional | | $1,669.10 | $2,128.53 | $2,396.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,878.45 / $2,486.19 / $2,762.43
| Professional | | $1,878.45 | $2,486.19 | $2,762.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $515.00 / $541.00 / $561.00
| Facility | | $515.00 | $541.00 | $561.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,746.77 / $2,492.38 / $3,209.56
| Professional | | $1,746.77 | $2,492.38 | $3,209.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $375.00 / $750.00 / $2,421.00
| Facility | | $375.00 | $750.00 | $2,421.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,599.80 / $2,178.50 / $3,629.73
| Professional | | $1,599.80 | $2,178.50 | $3,629.73 |