- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $2,492.30 / $4,389.47
| Facility | | $1,277.00 | $2,492.30 | $4,389.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,944.94 / $2,492.30 / $2,922.38
| Professional | | $1,944.94 | $2,492.30 | $2,922.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,985.80 / $2,628.27 / $2,628.27
| Professional | | $1,985.80 | $2,628.27 | $2,628.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,431.12 / $3,395.11 / $4,272.75
| Professional | | $2,431.12 | $3,395.11 | $4,272.75 |
- 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
- $1,827.30 / $2,198.09 / $4,136.45
| Professional | | $1,827.30 | $2,198.09 | $4,136.45 |