- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $2,280.94 / $4,041.82
| Facility | | $1,277.00 | $2,280.94 | $4,041.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,777.61 / $2,280.94 / $2,829.28
| Professional | | $1,777.61 | $2,280.94 | $2,829.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,829.35 / $2,421.19 / $2,421.19
| Professional | | $1,829.35 | $2,421.19 | $2,421.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,262.15 / $3,326.64 / $3,990.00
| Professional | | $2,262.15 | $3,326.64 | $3,990.00 |
- 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
- $1,777.71 / $2,312.66 / $3,786.20
| Professional | | $1,777.71 | $2,312.66 | $3,786.20 |