- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $1,890.50 / $3,331.38
| Facility | | $1,277.00 | $1,890.50 | $3,331.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,473.12 / $1,890.50 / $2,201.96
| Professional | | $1,473.12 | $1,890.50 | $2,201.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,503.71 / $1,990.21 / $1,990.21
| Professional | | $1,503.71 | $1,990.21 | $1,990.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,865.44 / $2,551.44 / $3,224.96
| Professional | | $1,865.44 | $2,551.44 | $3,224.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $375.00 / $1,230.00 / $2,421.00
| Facility | | $375.00 | $1,230.00 | $2,421.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,319.30 / $1,677.95 / $3,144.92
| Professional | | $1,319.30 | $1,677.95 | $3,144.92 |