- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $1,818.77 / $3,280.10
| Facility | | $1,277.00 | $1,818.77 | $3,280.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,485.56 / $1,818.77 / $2,245.75
| Professional | | $1,485.56 | $1,818.77 | $2,245.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,191.81 / $2,900.93 / $2,900.93
| Professional | | $2,191.81 | $2,900.93 | $2,900.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,845.00 / $2,615.89 / $3,311.12
| Professional | | $1,845.00 | $2,615.89 | $3,311.12 |
- 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
- $1,316.14 / $1,818.74 / $3,096.50
| Professional | | $1,316.14 | $1,818.74 | $3,096.50 |