- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $2,159.11 / $3,983.88
| Facility | | $1,277.00 | $2,159.11 | $3,983.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,649.80 / $2,217.98 / $2,556.71
| Professional | | $1,649.80 | $2,217.98 | $2,556.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,662.25 / $3,523.57 / $3,523.57
| Professional | | $2,662.25 | $3,523.57 | $3,523.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,434.69 / $3,188.68 / $4,035.01
| Professional | | $2,434.69 | $3,188.68 | $4,035.01 |
- 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
- $1,603.64 / $1,992.57 / $3,627.34
| Professional | | $1,603.64 | $1,992.57 | $3,627.34 |