- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $2,342.42 / $4,116.13
| Facility | | $1,277.00 | $2,342.42 | $4,116.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,708.00 / $2,342.42 / $2,787.48
| Professional | | $1,708.00 | $2,342.42 | $2,787.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,855.05 / $2,455.21 / $2,455.21
| Professional | | $1,855.05 | $2,455.21 | $2,455.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,312.29 / $3,185.15 / $4,003.83
| Professional | | $2,312.29 | $3,185.15 | $4,003.83 |
- 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
- $1,637.93 / $2,548.17 / $3,884.08
| Professional | | $1,637.93 | $2,548.17 | $3,884.08 |