- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $2,137.85 / $3,804.35
| Facility | | $1,277.00 | $2,137.85 | $3,804.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,664.61 / $2,137.85 / $2,663.04
| Professional | | $1,664.61 | $2,137.85 | $2,663.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,721.15 / $2,277.98 / $2,277.98
| Professional | | $1,721.15 | $2,277.98 | $2,277.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,120.92 / $3,116.61 / $4,395.00
| Professional | | $2,120.92 | $3,116.61 | $4,395.00 |
- 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
- $1,664.65 / $2,330.51 / $3,596.48
| Professional | | $1,664.65 | $2,330.51 | $3,596.48 |