- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $2,266.05 / $4,081.20
| Facility | | $1,277.00 | $2,266.05 | $4,081.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,887.40 / $2,285.34 / $2,801.35
| Professional | | $1,887.40 | $2,285.34 | $2,801.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,725.81 / $3,607.70 / $3,607.70
| Professional | | $2,725.81 | $3,607.70 | $3,607.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,155.00 / $3,278.32 / $4,148.87
| Professional | | $2,155.00 | $3,278.32 | $4,148.87 |
- 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
- $1,649.13 / $2,007.19 / $3,729.70
| Professional | | $1,649.13 | $2,007.19 | $3,729.70 |