- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $2,168.27 / $3,857.52
| Facility | | $1,277.00 | $2,168.27 | $3,857.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,687.38 / $2,168.27 / $2,597.26
| Professional | | $1,687.38 | $2,168.27 | $2,597.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,745.28 / $2,309.92 / $2,309.92
| Professional | | $1,745.28 | $2,309.92 | $2,309.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,150.87 / $3,160.78 / $4,435.00
| Professional | | $2,150.87 | $3,160.78 | $4,435.00 |
- 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
- $1,635.83 / $2,125.19 / $3,627.94
| Professional | | $1,635.83 | $2,125.19 | $3,627.94 |