- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $1,887.91 / $3,316.45
| Facility | | $1,277.00 | $1,887.91 | $3,316.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,448.77 / $1,861.91 / $2,321.51
| Professional | | $1,448.77 | $1,861.91 | $2,321.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,500.81 / $1,986.36 / $1,986.36
| Professional | | $1,500.81 | $1,986.36 | $1,986.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,830.54 / $2,688.30 / $3,565.00
| Professional | | $1,830.54 | $2,688.30 | $3,565.00 |
- 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
- $1,405.10 / $1,827.51 / $3,115.30
| Professional | | $1,405.10 | $1,827.51 | $3,115.30 |