- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $2,209.64 / $3,109.00
| Facility | | $1,277.00 | $2,209.64 | $3,109.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,545.73 / $2,234.63 / $2,430.60
| Professional | | $1,545.73 | $2,234.63 | $2,430.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,653.14 / $2,187.98 / $2,187.98
| Professional | | $1,653.14 | $2,187.98 | $2,187.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,059.50 / $2,854.28 / $3,500.00
| Professional | | $2,059.50 | $2,854.28 | $3,500.00 |
- 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
- $1,536.72 / $1,785.52 / $3,193.53
| Professional | | $1,536.72 | $1,785.52 | $3,193.53 |