- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $2,696.58 / $4,438.14
| Facility | | $1,277.00 | $2,696.58 | $4,438.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,091.55 / $2,696.58 / $3,225.68
| Professional | | $2,091.55 | $2,696.58 | $3,225.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,312.69 / $3,060.91 / $3,401.01
| Professional | | $2,312.69 | $3,060.91 | $3,401.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $515.00 / $541.00 / $561.00
| Facility | | $515.00 | $541.00 | $561.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.58 / $3,285.75 / $4,227.64
| Professional | | $2,187.58 | $3,285.75 | $4,227.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $375.00 / $750.00 / $2,558.00
| Facility | | $375.00 | $750.00 | $2,558.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,030.94 / $2,786.69 / $4,502.06
| Professional | | $2,030.94 | $2,786.69 | $4,502.06 |