- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $2,529.02 / $4,437.50
| Facility | | $1,277.00 | $2,529.02 | $4,437.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,231.42 / $2,529.02 / $3,159.27
| Professional | | $2,231.42 | $2,529.02 | $3,159.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,000.35 / $2,647.52 / $2,647.52
| Professional | | $2,000.35 | $2,647.52 | $2,647.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,472.54 / $3,625.29 / $4,332.47
| Professional | | $2,472.54 | $3,625.29 | $4,332.47 |
- 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
- $1,903.34 / $2,592.92 / $4,201.64
| Professional | | $1,903.34 | $2,592.92 | $4,201.64 |