- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $2,447.48 / $3,256.56
| Facility | | $1,277.00 | $2,447.48 | $3,256.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,693.88 / $2,468.85 / $2,692.22
| Professional | | $1,693.88 | $2,468.85 | $2,692.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,825.03 / $2,415.48 / $2,415.48
| Professional | | $1,825.03 | $2,415.48 | $2,415.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,870.00 / $2,832.24 / $3,410.55
| Professional | | $1,870.00 | $2,832.24 | $3,410.55 |
- 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
- $1,645.80 / $1,993.62 / $3,520.85
| Professional | | $1,645.80 | $1,993.62 | $3,520.85 |