- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $1,756.32 / $3,177.13
| Facility | | $1,277.00 | $1,756.32 | $3,177.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,029.93 / $1,756.32 / $2,170.03
| Professional | | $1,029.93 | $1,756.32 | $2,170.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,122.25 / $2,808.86 / $2,808.86
| Professional | | $2,122.25 | $2,808.86 | $2,808.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,813.25 / $2,498.79 / $3,197.05
| Professional | | $1,813.25 | $2,498.79 | $3,197.05 |
- 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
- $1,193.22 / $1,589.49 / $2,874.05
| Professional | | $1,193.22 | $1,589.49 | $2,874.05 |