- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $2,119.61 / $3,751.52
| Facility | | $1,277.00 | $2,119.61 | $3,751.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,651.51 / $2,119.61 / $2,620.62
| Professional | | $1,651.51 | $2,119.61 | $2,620.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,697.05 / $2,246.09 / $2,246.09
| Professional | | $1,697.05 | $2,246.09 | $2,246.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.42 / $2,870.10 / $3,630.68
| Professional | | $2,089.42 | $2,870.10 | $3,630.68 |
- 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
- $1,593.89 / $2,231.08 / $3,545.74
| Professional | | $1,593.89 | $2,231.08 | $3,545.74 |