- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $1,886.10 / $3,404.80
| Facility | | $1,277.00 | $1,886.10 | $3,404.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,447.20 / $1,886.10 / $2,451.63
| Professional | | $1,447.20 | $1,886.10 | $2,451.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,728.39 / $2,160.48 / $2,287.58
| Professional | | $1,728.39 | $2,160.48 | $2,287.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,670.67 / $2,382.69 / $3,281.32
| Professional | | $1,670.67 | $2,382.69 | $3,281.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $375.00 / $900.00 / $2,421.00
| Facility | | $375.00 | $900.00 | $2,421.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.78 / $1,892.37 / $3,086.15
| Professional | | $1,380.78 | $1,892.37 | $3,086.15 |