- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $2,182.56 / $3,867.42
| Facility | | $1,277.00 | $2,182.56 | $3,867.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,783.94 / $2,182.56 / $2,597.25
| Professional | | $1,783.94 | $2,182.56 | $2,597.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,749.95 / $2,316.11 / $2,316.11
| Professional | | $1,749.95 | $2,316.11 | $2,316.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,165.10 / $3,184.13 / $3,742.99
| Professional | | $2,165.10 | $3,184.13 | $3,742.99 |
- 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
- $1,646.82 / $2,307.35 / $3,655.42
| Professional | | $1,646.82 | $2,307.35 | $3,655.42 |