- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $2,500.00 / $3,862.58
| Facility | | $1,277.00 | $2,500.00 | $3,862.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,968.17 / $2,838.57 / $2,838.57
| Professional | | $1,968.17 | $2,838.57 | $2,838.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,174.21 / $2,877.64 / $2,877.64
| Professional | | $2,174.21 | $2,877.64 | $2,877.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,947.74 / $3,073.61 / $4,071.97
| Professional | | $1,947.74 | $3,073.61 | $4,071.97 |
- 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
- $1,858.74 / $2,259.92 / $4,111.70
| Professional | | $1,858.74 | $2,259.92 | $4,111.70 |