- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $2,131.84 / $3,460.47
| Facility | | $1,277.00 | $2,131.84 | $3,460.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,666.84 / $2,131.84 / $2,509.73
| Professional | | $1,666.84 | $2,131.84 | $2,509.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,559.78 / $2,064.42 / $2,064.42
| Professional | | $1,559.78 | $2,064.42 | $2,064.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,690.00 / $2,852.26 / $3,371.56
| Professional | | $1,690.00 | $2,852.26 | $3,371.56 |
- 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
- $1,532.53 / $2,138.04 / $3,274.04
| Professional | | $1,532.53 | $2,138.04 | $3,274.04 |