- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $2,556.66 / $4,512.52
| Facility | | $1,277.00 | $2,556.66 | $4,512.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,099.25 / $2,556.66 / $3,137.31
| Professional | | $2,099.25 | $2,556.66 | $3,137.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.29 / $2,701.71 / $2,701.71
| Professional | | $2,041.29 | $2,701.71 | $2,701.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,534.06 / $3,725.55 / $4,382.62
| Professional | | $2,534.06 | $3,725.55 | $4,382.62 |
- 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
- $1,992.10 / $2,451.03 / $4,271.01
| Professional | | $1,992.10 | $2,451.03 | $4,271.01 |