- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $1,843.79 / $3,140.22
| Facility | | $1,277.00 | $1,843.79 | $3,140.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,428.84 / $1,843.79 / $2,198.16
| Professional | | $1,428.84 | $1,843.79 | $2,198.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,415.52 / $1,873.48 / $1,873.48
| Professional | | $1,415.52 | $1,873.48 | $1,873.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,804.64 / $2,521.03 / $3,057.26
| Professional | | $1,804.64 | $2,521.03 | $3,057.26 |
- 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
- $1,343.83 / $1,945.54 / $2,972.33
| Professional | | $1,343.83 | $1,945.54 | $2,972.33 |