- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $2,500.00 / $4,076.38
| Facility | | $1,277.00 | $2,500.00 | $4,076.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,207.81 / $3,044.06 / $3,044.06
| Professional | | $2,207.81 | $3,044.06 | $3,044.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,262.39 / $2,994.34 / $2,994.34
| Professional | | $2,262.39 | $2,994.34 | $2,994.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,555.73 / $3,667.26 / $4,862.27
| Professional | | $2,555.73 | $3,667.26 | $4,862.27 |
- 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
- $1,965.87 / $2,436.03 / $4,426.32
| Professional | | $1,965.87 | $2,436.03 | $4,426.32 |