- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,181.00 / $1,953.38 / $3,521.60
| Facility | | $1,181.00 | $1,953.38 | $3,521.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,607.45 / $1,953.38 / $2,409.61
| Professional | | $1,607.45 | $1,953.38 | $2,409.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,352.58 / $3,113.71 / $3,113.71
| Professional | | $2,352.58 | $3,113.71 | $3,113.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,902.71 / $2,786.63 / $3,554.52
| Professional | | $1,902.71 | $2,786.63 | $3,554.52 |
- 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
- $1,408.64 / $1,773.42 / $3,195.40
| Professional | | $1,408.64 | $1,773.42 | $3,195.40 |