- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $2,363.65 / $4,169.18
| Facility | | $1,277.00 | $2,363.65 | $4,169.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,940.95 / $2,363.65 / $2,746.41
| Professional | | $1,940.95 | $2,363.65 | $2,746.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,885.80 / $2,495.91 / $2,495.91
| Professional | | $1,885.80 | $2,495.91 | $2,495.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,342.35 / $3,195.00 / $4,050.22
| Professional | | $2,342.35 | $3,195.00 | $4,050.22 |
- 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
- $1,764.27 / $2,746.41 / $3,955.47
| Professional | | $1,764.27 | $2,746.41 | $3,955.47 |