- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $2,298.17 / $4,036.85
| Facility | | $1,277.00 | $2,298.17 | $4,036.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,790.74 / $2,298.17 / $2,925.42
| Professional | | $1,790.74 | $2,298.17 | $2,925.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.43 / $2,408.07 / $2,408.07
| Professional | | $1,819.43 | $2,408.07 | $2,408.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,237.94 / $3,185.15 / $3,936.48
| Professional | | $2,237.94 | $3,185.15 | $3,936.48 |
- 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
- $1,610.38 / $2,505.03 / $3,810.91
| Professional | | $1,610.38 | $2,505.03 | $3,810.91 |