- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $1,821.00 / $4,804.33
| Facility | | $1,277.00 | $1,821.00 | $4,804.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.01 / $1,716.72 / $2,100.19
| Professional | | $1,412.01 | $1,716.72 | $2,100.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,052.14 / $2,716.07 / $2,716.07
| Professional | | $2,052.14 | $2,716.07 | $2,716.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,385.00 / $2,436.37 / $3,110.04
| Professional | | $1,385.00 | $2,436.37 | $3,110.04 |
- 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
- $1,238.94 / $1,674.47 / $2,795.82
| Professional | | $1,238.94 | $1,674.47 | $2,795.82 |