- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $2,454.98 / $4,336.55
| Facility | | $1,277.00 | $2,454.98 | $4,336.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,913.98 / $2,454.98 / $3,035.58
| Professional | | $1,913.98 | $2,454.98 | $3,035.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,962.24 / $2,597.08 / $2,597.08
| Professional | | $1,962.24 | $2,597.08 | $2,597.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,432.44 / $3,370.28 / $4,202.89
| Professional | | $2,432.44 | $3,370.28 | $4,202.89 |
- 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
- $1,910.41 / $2,273.39 / $4,103.56
| Professional | | $1,910.41 | $2,273.39 | $4,103.56 |