- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $2,482.05 / $4,386.02
| Facility | | $1,277.00 | $2,482.05 | $4,386.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,934.71 / $2,482.05 / $3,026.17
| Professional | | $1,934.71 | $2,482.05 | $3,026.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,984.04 / $2,625.94 / $2,625.94
| Professional | | $1,984.04 | $2,625.94 | $2,625.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,458.50 / $3,614.65 / $4,250.41
| Professional | | $2,458.50 | $3,614.65 | $4,250.41 |
- 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
- $1,738.81 / $2,735.78 / $4,150.14
| Professional | | $1,738.81 | $2,735.78 | $4,150.14 |