- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $2,144.19 / $3,765.55
| Facility | | $1,277.00 | $2,144.19 | $3,765.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,704.73 / $2,144.19 / $2,635.89
| Professional | | $1,704.73 | $2,144.19 | $2,635.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,697.46 / $2,246.64 / $2,246.64
| Professional | | $1,697.46 | $2,246.64 | $2,246.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,101.05 / $2,936.50 / $3,673.00
| Professional | | $2,101.05 | $2,936.50 | $3,673.00 |
- 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
- $1,553.74 / $2,371.71 / $3,564.27
| Professional | | $1,553.74 | $2,371.71 | $3,564.27 |