- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $2,175.00 / $4,010.20
| Facility | | $1,277.00 | $2,175.00 | $4,010.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,836.82 / $2,230.02 / $2,745.51
| Professional | | $1,836.82 | $2,230.02 | $2,745.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,679.44 / $3,546.32 / $3,546.32
| Professional | | $2,679.44 | $3,546.32 | $3,546.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,461.38 / $3,223.90 / $4,055.93
| Professional | | $2,461.38 | $3,223.90 | $4,055.93 |
- 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
- $1,573.33 / $2,016.23 / $3,646.14
| Professional | | $1,573.33 | $2,016.23 | $3,646.14 |