- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $2,500.00 / $5,122.45
| Facility | | $1,277.00 | $2,500.00 | $5,122.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,270.13 / $2,917.54 / $3,254.51
| Professional | | $2,270.13 | $2,917.54 | $3,254.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,311.94 / $3,059.94 / $3,059.94
| Professional | | $2,311.94 | $3,059.94 | $3,059.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,486.02 / $3,765.22 / $4,982.64
| Professional | | $2,486.02 | $3,765.22 | $4,982.64 |
- 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
- $1,913.04 / $2,495.54 / $4,823.70
| Professional | | $1,913.04 | $2,495.54 | $4,823.70 |