- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $1,900.74 / $3,410.57
| Facility | | $1,277.00 | $1,900.74 | $3,410.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,565.50 / $1,900.74 / $2,333.89
| Professional | | $1,565.50 | $1,900.74 | $2,333.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,277.61 / $3,014.49 / $3,014.49
| Professional | | $2,277.61 | $3,014.49 | $3,014.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.00 / $2,745.44 / $3,451.86
| Professional | | $1,905.00 | $2,745.44 | $3,451.86 |
- 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
- $1,388.30 / $1,733.15 / $3,103.10
| Professional | | $1,388.30 | $1,733.15 | $3,103.10 |