- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $2,233.44 / $3,970.00
| Facility | | $1,277.00 | $2,233.44 | $3,970.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.28 / $2,233.44 / $2,779.00
| Professional | | $1,819.28 | $2,233.44 | $2,779.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,796.44 / $2,377.64 / $2,377.64
| Professional | | $1,796.44 | $2,377.64 | $2,377.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,215.66 / $3,175.00 / $3,825.88
| Professional | | $2,215.66 | $3,175.00 | $3,825.88 |
- 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
- $1,737.71 / $2,384.58 / $3,736.36
| Professional | | $1,737.71 | $2,384.58 | $3,736.36 |