- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $2,238.78 / $3,747.37
| Facility | | $1,277.00 | $2,238.78 | $3,747.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,738.68 / $2,216.31 / $2,495.19
| Professional | | $1,738.68 | $2,216.31 | $2,495.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,955.10 / $2,587.64 / $2,875.15
| Professional | | $1,955.10 | $2,587.64 | $2,875.15 |
- 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
- $1,788.49 / $2,615.00 / $3,344.02
| Professional | | $1,788.49 | $2,615.00 | $3,344.02 |
- 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
- $1,646.60 / $2,227.10 / $3,768.33
| Professional | | $1,646.60 | $2,227.10 | $3,768.33 |