- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $1,858.55 / $3,330.15
| Facility | | $1,277.00 | $1,858.55 | $3,330.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,501.92 / $1,858.55 / $2,283.55
| Professional | | $1,501.92 | $1,858.55 | $2,283.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,690.24 / $2,237.09 / $2,237.09
| Professional | | $1,690.24 | $2,237.09 | $2,237.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,710.00 / $2,675.57 / $3,376.64
| Professional | | $1,710.00 | $2,675.57 | $3,376.64 |
- 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
- $1,356.15 / $1,678.33 / $3,035.49
| Professional | | $1,356.15 | $1,678.33 | $3,035.49 |