- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $2,470.30 / $4,152.05
| Facility | | $1,277.00 | $2,470.30 | $4,152.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,920.01 / $2,470.30 / $2,984.70
| Professional | | $1,920.01 | $2,470.30 | $2,984.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,871.50 / $2,476.98 / $2,476.98
| Professional | | $1,871.50 | $2,476.98 | $2,476.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,155.00 / $3,353.46 / $4,049.08
| Professional | | $2,155.00 | $3,353.46 | $4,049.08 |
- 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
- $1,839.70 / $2,391.76 / $3,930.84
| Professional | | $1,839.70 | $2,391.76 | $3,930.84 |