- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $2,066.76 / $3,632.15
| Facility | | $1,277.00 | $2,066.76 | $3,632.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,622.96 / $2,066.76 / $2,638.05
| Professional | | $1,622.96 | $2,066.76 | $2,638.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,637.03 / $2,166.65 / $2,166.65
| Professional | | $1,637.03 | $2,166.65 | $2,166.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,013.78 / $2,851.84 / $3,539.76
| Professional | | $2,013.78 | $2,851.84 | $3,539.76 |
- 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
- $1,608.98 / $1,998.53 / $3,222.38
| Professional | | $1,608.98 | $1,998.53 | $3,222.38 |