- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $1,846.83 / $3,268.65
| Facility | | $1,277.00 | $1,846.83 | $3,268.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,424.54 / $1,831.85 / $2,232.08
| Professional | | $1,424.54 | $1,831.85 | $2,232.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.63 / $1,958.34 / $1,958.34
| Professional | | $1,479.63 | $1,958.34 | $1,958.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,793.91 / $2,480.06 / $3,137.35
| Professional | | $1,793.91 | $2,480.06 | $3,137.35 |
- 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
- $1,426.07 / $1,983.50 / $3,063.95
| Professional | | $1,426.07 | $1,983.50 | $3,063.95 |