- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $2,406.80 / $4,272.22
| Facility | | $1,277.00 | $2,406.80 | $4,272.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,875.24 / $2,406.80 / $2,840.21
| Professional | | $1,875.24 | $2,406.80 | $2,840.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,932.97 / $2,558.35 / $2,558.35
| Professional | | $1,932.97 | $2,558.35 | $2,558.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,387.07 / $3,372.75 / $4,465.00
| Professional | | $2,387.07 | $3,372.75 | $4,465.00 |
- 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
- $1,815.12 / $2,642.58 / $4,041.05
| Professional | | $1,815.12 | $2,642.58 | $4,041.05 |