- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $1,821.00 / $3,124.98
| Facility | | $1,277.00 | $1,821.00 | $3,124.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,366.96 / $1,759.93 / $2,127.02
| Professional | | $1,366.96 | $1,759.93 | $2,127.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,411.69 / $1,868.41 / $1,868.41
| Professional | | $1,411.69 | $1,868.41 | $1,868.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,744.14 / $2,372.91 / $3,008.24
| Professional | | $1,744.14 | $2,372.91 | $3,008.24 |
- 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
- $1,367.38 / $1,876.12 / $2,937.86
| Professional | | $1,367.38 | $1,876.12 | $2,937.86 |