- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $1,821.00 / $3,148.53
| Facility | | $1,277.00 | $1,821.00 | $3,148.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,371.83 / $1,763.89 / $2,181.86
| Professional | | $1,371.83 | $1,763.89 | $2,181.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,424.70 / $1,885.64 / $1,885.64
| Professional | | $1,424.70 | $1,885.64 | $1,885.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,735.55 / $2,547.65 / $3,020.05
| Professional | | $1,735.55 | $2,547.65 | $3,020.05 |
- 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
- $1,331.18 / $1,953.80 / $2,949.39
| Professional | | $1,331.18 | $1,953.80 | $2,949.39 |