- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $2,067.56 / $3,454.09
| Facility | | $1,277.00 | $2,067.56 | $3,454.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,602.91 / $2,043.76 / $2,447.17
| Professional | | $1,602.91 | $2,043.76 | $2,447.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,801.71 / $2,384.62 / $2,649.58
| Professional | | $1,801.71 | $2,384.62 | $2,649.58 |
- 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
- $1,675.14 / $2,511.81 / $3,087.40
| Professional | | $1,675.14 | $2,511.81 | $3,087.40 |
- 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
- $1,554.62 / $2,141.28 / $3,303.56
| Professional | | $1,554.62 | $2,141.28 | $3,303.56 |