- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $1,821.00 / $3,129.18
| Facility | | $1,277.00 | $1,821.00 | $3,129.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,364.00 / $1,753.79 / $2,079.73
| Professional | | $1,364.00 | $1,753.79 | $2,079.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,416.83 / $1,875.21 / $1,875.21
| Professional | | $1,416.83 | $1,875.21 | $1,875.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,735.42 / $2,548.09 / $3,001.87
| Professional | | $1,735.42 | $2,548.09 | $3,001.87 |
- 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
- $1,364.48 / $1,983.95 / $2,931.63
| Professional | | $1,364.48 | $1,983.95 | $2,931.63 |