- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $2,310.14 / $4,085.15
| Facility | | $1,277.00 | $2,310.14 | $4,085.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,844.90 / $2,310.14 / $2,720.59
| Professional | | $1,844.90 | $2,310.14 | $2,720.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,848.02 / $2,445.91 / $2,445.91
| Professional | | $1,848.02 | $2,445.91 | $2,445.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,289.21 / $3,016.87 / $3,956.29
| Professional | | $2,289.21 | $3,016.87 | $3,956.29 |
- 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
- $1,798.31 / $2,061.05 / $3,601.57
| Professional | | $1,798.31 | $2,061.05 | $3,601.57 |