- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $1,821.00 / $3,207.25
| Facility | | $1,277.00 | $1,821.00 | $3,207.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,387.55 / $1,792.04 / $2,143.01
| Professional | | $1,387.55 | $1,792.04 | $2,143.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.98 / $2,027.48 / $2,146.73
| Professional | | $1,621.98 | $2,027.48 | $2,146.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,593.16 / $2,297.94 / $3,137.05
| Professional | | $1,593.16 | $2,297.94 | $3,137.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $375.00 / $1,151.00 / $2,421.00
| Facility | | $375.00 | $1,151.00 | $2,421.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,341.31 / $1,896.58 / $3,020.61
| Professional | | $1,341.31 | $1,896.58 | $3,020.61 |