- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $2,274.14 / $3,997.05
| Facility | | $1,277.00 | $2,274.14 | $3,997.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,745.70 / $2,274.14 / $2,669.52
| Professional | | $1,745.70 | $2,274.14 | $2,669.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,804.21 / $2,387.92 / $2,387.92
| Professional | | $1,804.21 | $2,387.92 | $2,387.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,251.75 / $3,094.72 / $3,867.06
| Professional | | $2,251.75 | $3,094.72 | $3,867.06 |
- 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
- $1,705.10 / $2,365.65 / $3,773.81
| Professional | | $1,705.10 | $2,365.65 | $3,773.81 |