- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $2,720.10 / $4,613.60
| Facility | | $1,277.00 | $2,720.10 | $4,613.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,132.28 / $2,720.10 / $3,317.16
| Professional | | $2,132.28 | $2,720.10 | $3,317.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,127.94 / $2,816.40 / $2,816.40
| Professional | | $2,127.94 | $2,816.40 | $2,816.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,679.67 / $3,721.54 / $4,643.75
| Professional | | $2,679.67 | $3,721.54 | $4,643.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $375.00 / $1,230.00 / $2,421.00
| Facility | | $375.00 | $1,230.00 | $2,421.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,081.42 / $2,955.12 / $4,463.18
| Professional | | $2,081.42 | $2,955.12 | $4,463.18 |