- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $1,888.11 / $3,318.77
| Facility | | $1,277.00 | $1,888.11 | $3,318.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,449.65 / $1,863.49 / $2,217.55
| Professional | | $1,449.65 | $1,863.49 | $2,217.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,501.85 / $1,987.75 / $1,987.75
| Professional | | $1,501.85 | $1,987.75 | $1,987.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,842.56 / $2,650.00 / $3,191.93
| Professional | | $1,842.56 | $2,650.00 | $3,191.93 |
- 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
- $1,405.69 / $2,046.77 / $3,117.26
| Professional | | $1,405.69 | $2,046.77 | $3,117.26 |