- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $2,495.69 / $3,723.68
| Facility | | $1,277.00 | $2,495.69 | $3,723.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,908.83 / $2,736.25 / $2,736.25
| Professional | | $1,908.83 | $2,736.25 | $2,736.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,093.37 / $2,770.63 / $2,770.63
| Professional | | $2,093.37 | $2,770.63 | $2,770.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,876.33 / $2,958.76 / $3,918.38
| Professional | | $1,876.33 | $2,958.76 | $3,918.38 |
- 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
- $1,790.83 / $2,179.44 / $3,956.60
| Professional | | $1,790.83 | $2,179.44 | $3,956.60 |