- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $2,166.73 / $3,857.63
| Facility | | $1,277.00 | $2,166.73 | $3,857.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,686.54 / $2,166.73 / $2,700.34
| Professional | | $1,686.54 | $2,166.73 | $2,700.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,745.58 / $2,310.33 / $2,310.33
| Professional | | $1,745.58 | $2,310.33 | $2,310.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,149.69 / $3,050.00 / $3,711.53
| Professional | | $2,149.69 | $3,050.00 | $3,711.53 |
- 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
- $1,634.57 / $2,361.88 / $3,624.70
| Professional | | $1,634.57 | $2,361.88 | $3,624.70 |