- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $1,955.38 / $3,566.05
| Facility | | $1,277.00 | $1,955.38 | $3,566.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,489.47 / $1,955.38 / $2,326.90
| Professional | | $1,489.47 | $1,955.38 | $2,326.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,811.45 / $2,264.31 / $2,397.50
| Professional | | $1,811.45 | $2,264.31 | $2,397.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,525.00 / $2,387.53 / $3,403.23
| Professional | | $1,525.00 | $2,387.53 | $3,403.23 |
- 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
- $1,412.74 / $1,896.40 / $3,182.85
| Professional | | $1,412.74 | $1,896.40 | $3,182.85 |