- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $1,893.71 / $3,346.98
| Facility | | $1,277.00 | $1,893.71 | $3,346.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,473.14 / $1,893.71 / $2,280.37
| Professional | | $1,473.14 | $1,893.71 | $2,280.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,511.19 / $2,000.11 / $2,000.11
| Professional | | $1,511.19 | $2,000.11 | $2,000.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,869.51 / $2,566.25 / $3,234.50
| Professional | | $1,869.51 | $2,566.25 | $3,234.50 |
- 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
- $1,328.51 / $1,930.39 / $3,158.83
| Professional | | $1,328.51 | $1,930.39 | $3,158.83 |