- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $2,338.48 / $4,124.02
| Facility | | $1,277.00 | $2,338.48 | $4,124.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,810.56 / $2,338.48 / $2,782.79
| Professional | | $1,810.56 | $2,338.48 | $2,782.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,861.83 / $2,464.19 / $2,464.19
| Professional | | $1,861.83 | $2,464.19 | $2,464.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,318.00 / $3,197.95 / $4,006.16
| Professional | | $2,318.00 | $3,197.95 | $4,006.16 |
- 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
- $1,760.79 / $2,268.73 / $3,893.28
| Professional | | $1,760.79 | $2,268.73 | $3,893.28 |