- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $2,028.00 / $3,150.39
| Facility | | $1,277.00 | $2,028.00 | $3,150.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,681.83 / $1,947.13 / $2,373.94
| Professional | | $1,681.83 | $1,947.13 | $2,373.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,628.33 / $2,155.14 / $2,155.14
| Professional | | $1,628.33 | $2,155.14 | $2,155.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,978.93 / $2,831.91 / $3,097.33
| Professional | | $1,978.93 | $2,831.91 | $3,097.33 |
- 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
- $1,607.90 / $2,030.37 / $3,389.71
| Professional | | $1,607.90 | $2,030.37 | $3,389.71 |