- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $2,028.00 / $3,482.30
| Facility | | $1,277.00 | $2,028.00 | $3,482.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,776.77 / $1,981.09 / $2,489.04
| Professional | | $1,776.77 | $1,981.09 | $2,489.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,570.02 / $2,077.96 / $2,077.96
| Professional | | $1,570.02 | $2,077.96 | $2,077.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,750.00 / $2,873.28 / $3,393.41
| Professional | | $1,750.00 | $2,873.28 | $3,393.41 |
- 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
- $1,491.09 / $2,091.62 / $3,314.02
| Professional | | $1,491.09 | $2,091.62 | $3,314.02 |