- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $2,383.44 / $4,201.05
| Facility | | $1,277.00 | $2,383.44 | $4,201.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,860.62 / $2,383.44 / $2,912.25
| Professional | | $1,860.62 | $2,383.44 | $2,912.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,900.29 / $2,515.10 / $2,515.10
| Professional | | $1,900.29 | $2,515.10 | $2,515.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,362.44 / $3,227.68 / $4,085.79
| Professional | | $2,362.44 | $3,227.68 | $4,085.79 |
- 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
- $1,857.18 / $2,274.73 / $3,955.46
| Professional | | $1,857.18 | $2,274.73 | $3,955.46 |