- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $2,480.73 / $4,378.50
| Facility | | $1,277.00 | $2,480.73 | $4,378.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,934.55 / $2,480.73 / $3,012.96
| Professional | | $1,934.55 | $2,480.73 | $3,012.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,980.43 / $2,621.16 / $2,621.16
| Professional | | $1,980.43 | $2,621.16 | $2,621.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,410.07 / $3,358.29 / $4,250.31
| Professional | | $2,410.07 | $3,358.29 | $4,250.31 |
- 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
- $1,854.43 / $2,672.55 / $4,150.87
| Professional | | $1,854.43 | $2,672.55 | $4,150.87 |