- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $2,418.32 / $4,274.80
| Facility | | $1,277.00 | $2,418.32 | $4,274.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,885.60 / $2,418.32 / $2,942.56
| Professional | | $1,885.60 | $2,418.32 | $2,942.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,933.87 / $2,559.54 / $2,559.54
| Professional | | $1,933.87 | $2,559.54 | $2,559.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,396.63 / $3,525.79 / $4,555.00
| Professional | | $2,396.63 | $3,525.79 | $4,555.00 |
- 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
- $1,882.72 / $2,229.21 / $4,009.85
| Professional | | $1,882.72 | $2,229.21 | $4,009.85 |