- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $1,863.13 / $3,270.73
| Facility | | $1,277.00 | $1,863.13 | $3,270.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,426.02 / $1,833.85 / $2,289.51
| Professional | | $1,426.02 | $1,833.85 | $2,289.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,480.61 / $1,959.63 / $1,959.63
| Professional | | $1,480.61 | $1,959.63 | $1,959.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,818.97 / $2,671.55 / $3,510.00
| Professional | | $1,818.97 | $2,671.55 | $3,510.00 |
- 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
- $1,385.00 / $2,006.45 / $3,066.62
| Professional | | $1,385.00 | $2,006.45 | $3,066.62 |