- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $1,994.64 / $3,600.68
| Facility | | $1,277.00 | $1,994.64 | $3,600.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,640.49 / $1,994.64 / $2,459.31
| Professional | | $1,640.49 | $1,994.64 | $2,459.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,406.08 / $3,184.52 / $3,184.52
| Professional | | $2,406.08 | $3,184.52 | $3,184.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,202.21 / $2,882.64 / $3,629.66
| Professional | | $2,202.21 | $2,882.64 | $3,629.66 |
- 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
- $1,460.09 / $2,050.23 / $3,262.95
| Professional | | $1,460.09 | $2,050.23 | $3,262.95 |