- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $2,372.36 / $3,443.27
| Facility | | $1,277.00 | $2,372.36 | $3,443.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,757.35 / $2,526.12 / $2,526.12
| Professional | | $1,757.35 | $2,526.12 | $2,526.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,937.90 / $2,564.87 / $2,564.87
| Professional | | $1,937.90 | $2,564.87 | $2,564.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,733.14 / $2,737.33 / $3,627.02
| Professional | | $1,733.14 | $2,737.33 | $3,627.02 |
- 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
- $1,647.59 / $2,015.24 / $3,662.41
| Professional | | $1,647.59 | $2,015.24 | $3,662.41 |