- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $1,867.75 / $3,403.25
| Facility | | $1,277.00 | $1,867.75 | $3,403.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,554.36 / $1,887.17 / $2,329.84
| Professional | | $1,554.36 | $1,887.17 | $2,329.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,273.04 / $3,008.43 / $3,008.43
| Professional | | $2,273.04 | $3,008.43 | $3,008.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,062.54 / $2,729.74 / $3,436.42
| Professional | | $2,062.54 | $2,729.74 | $3,436.42 |
- 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
- $1,301.77 / $1,708.07 / $3,089.22
| Professional | | $1,301.77 | $1,708.07 | $3,089.22 |