- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $1,806.23 / $3,256.93
| Facility | | $1,277.00 | $1,806.23 | $3,256.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,466.79 / $1,806.23 / $2,228.30
| Professional | | $1,466.79 | $1,806.23 | $2,228.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,175.31 / $2,879.08 / $2,879.08
| Professional | | $2,175.31 | $2,879.08 | $2,879.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,985.14 / $2,599.44 / $3,294.60
| Professional | | $1,985.14 | $2,599.44 | $3,294.60 |
- 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
- $1,314.05 / $1,669.62 / $2,997.02
| Professional | | $1,314.05 | $1,669.62 | $2,997.02 |