- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $2,070.90 / $3,699.73
| Facility | | $1,277.00 | $2,070.90 | $3,699.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,627.08 / $2,088.10 / $3,162.85
| Professional | | $1,627.08 | $2,088.10 | $3,162.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,673.32 / $2,214.67 / $2,214.67
| Professional | | $1,673.32 | $2,214.67 | $2,214.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,059.94 / $2,709.86 / $3,577.77
| Professional | | $2,059.94 | $2,709.86 | $3,577.77 |
- 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
- $1,565.77 / $1,937.28 / $3,494.07
| Professional | | $1,565.77 | $1,937.28 | $3,494.07 |