- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $2,483.63 / $4,620.35
| Facility | | $1,277.00 | $2,483.63 | $4,620.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,999.92 / $2,580.48 / $3,171.58
| Professional | | $1,999.92 | $2,580.48 | $3,171.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,085.82 / $4,084.17 / $4,084.17
| Professional | | $3,085.82 | $4,084.17 | $4,084.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,740.00 / $3,644.92 / $4,694.57
| Professional | | $2,740.00 | $3,644.92 | $4,694.57 |
- 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
- $1,867.04 / $2,483.63 / $4,281.74
| Professional | | $1,867.04 | $2,483.63 | $4,281.74 |