- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $2,443.90 / $4,318.05
| Facility | | $1,277.00 | $2,443.90 | $4,318.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,001.43 / $2,443.90 / $3,037.39
| Professional | | $2,001.43 | $2,443.90 | $3,037.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,780.93 / $2,357.12 / $2,357.12
| Professional | | $1,780.93 | $2,357.12 | $2,357.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,421.73 / $3,494.19 / $4,184.34
| Professional | | $2,421.73 | $3,494.19 | $4,184.34 |
- 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
- $1,901.97 / $2,588.41 / $4,086.44
| Professional | | $1,901.97 | $2,588.41 | $4,086.44 |