- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $2,414.73 / $3,225.35
| Facility | | $1,277.00 | $2,414.73 | $3,225.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,697.82 / $2,442.82 / $2,656.20
| Professional | | $1,697.82 | $2,442.82 | $2,656.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,807.47 / $2,392.23 / $2,392.23
| Professional | | $1,807.47 | $2,392.23 | $2,392.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,235.80 / $3,060.00 / $3,376.36
| Professional | | $2,235.80 | $3,060.00 | $3,376.36 |
- 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
- $1,651.44 / $1,934.81 / $3,481.50
| Professional | | $1,651.44 | $1,934.81 | $3,481.50 |