- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $2,276.33 / $4,013.50
| Facility | | $1,277.00 | $2,276.33 | $4,013.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,867.84 / $2,276.33 / $2,631.73
| Professional | | $1,867.84 | $2,276.33 | $2,631.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,816.14 / $2,403.71 / $2,403.71
| Professional | | $1,816.14 | $2,403.71 | $2,403.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,255.44 / $2,981.63 / $3,900.05
| Professional | | $2,255.44 | $2,981.63 | $3,900.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $375.00 / $1,230.00 / $2,421.00
| Facility | | $375.00 | $1,230.00 | $2,421.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,714.33 / $2,366.16 / $3,808.81
| Professional | | $1,714.33 | $2,366.16 | $3,808.81 |