- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $2,322.17 / $3,483.27
| Facility | | $1,277.00 | $2,322.17 | $3,483.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,690.84 / $2,322.17 / $2,586.42
| Professional | | $1,690.84 | $2,322.17 | $2,586.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,739.43 / $2,302.19 / $2,302.19
| Professional | | $1,739.43 | $2,302.19 | $2,302.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,138.94 / $2,951.98 / $3,701.41
| Professional | | $2,138.94 | $2,951.98 | $3,701.41 |
- 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
- $1,661.58 / $1,929.61 / $3,614.82
| Professional | | $1,661.58 | $1,929.61 | $3,614.82 |