- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $2,028.00 / $3,398.58
| Facility | | $1,277.00 | $2,028.00 | $3,398.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,541.30 / $1,932.88 / $2,443.19
| Professional | | $1,541.30 | $1,932.88 | $2,443.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,532.03 / $2,027.68 / $2,027.68
| Professional | | $1,532.03 | $2,027.68 | $2,027.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,565.00 / $2,658.14 / $3,310.49
| Professional | | $1,565.00 | $2,658.14 | $3,310.49 |
- 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
- $1,454.67 / $2,106.67 / $3,216.10
| Professional | | $1,454.67 | $2,106.67 | $3,216.10 |