- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $2,224.46 / $3,109.00
| Facility | | $1,277.00 | $2,224.46 | $3,109.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,537.88 / $2,224.46 / $2,374.00
| Professional | | $1,537.88 | $2,224.46 | $2,374.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,646.56 / $2,179.27 / $2,179.27
| Professional | | $1,646.56 | $2,179.27 | $2,179.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,010.62 / $2,690.78 / $3,075.37
| Professional | | $2,010.62 | $2,690.78 | $3,075.37 |
- 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
- $1,488.27 / $1,839.96 / $3,400.89
| Professional | | $1,488.27 | $1,839.96 | $3,400.89 |