- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $2,477.00 / $3,393.77
| Facility | | $1,277.00 | $2,477.00 | $3,393.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,796.55 / $2,569.17 / $2,799.46
| Professional | | $1,796.55 | $2,569.17 | $2,799.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,902.44 / $2,517.92 / $2,517.92
| Professional | | $1,902.44 | $2,517.92 | $2,517.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,870.00 / $2,897.32 / $3,551.73
| Professional | | $1,870.00 | $2,897.32 | $3,551.73 |
- 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
- $1,687.80 / $2,035.56 / $3,661.67
| Professional | | $1,687.80 | $2,035.56 | $3,661.67 |