- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $2,417.42 / $4,290.08
| Facility | | $1,277.00 | $2,417.42 | $4,290.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,884.03 / $2,417.42 / $2,876.73
| Professional | | $1,884.03 | $2,417.42 | $2,876.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,941.11 / $2,569.11 / $2,569.11
| Professional | | $1,941.11 | $2,569.11 | $2,569.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,360.16 / $3,273.71 / $4,143.54
| Professional | | $2,360.16 | $3,273.71 | $4,143.54 |
- 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
- $1,819.02 / $2,584.85 / $4,046.61
| Professional | | $1,819.02 | $2,584.85 | $4,046.61 |