- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $1,814.92 / $3,109.00
| Facility | | $1,277.00 | $1,814.92 | $3,109.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,394.74 / $1,759.18 / $1,956.61
| Professional | | $1,394.74 | $1,759.18 | $1,956.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,535.92 / $2,032.83 / $2,032.83
| Professional | | $1,535.92 | $2,032.83 | $2,032.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,667.09 / $2,485.00 / $2,653.21
| Professional | | $1,667.09 | $2,485.00 | $2,653.21 |
- 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
- $1,328.44 / $1,662.64 / $2,882.12
| Professional | | $1,328.44 | $1,662.64 | $2,882.12 |