- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $2,334.75 / $4,237.50
| Facility | | $1,277.00 | $2,334.75 | $4,237.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.07 / $2,362.31 / $2,906.35
| Professional | | $1,949.07 | $2,362.31 | $2,906.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,830.15 / $3,745.79 / $3,745.79
| Professional | | $2,830.15 | $3,745.79 | $3,745.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,572.39 / $3,368.43 / $4,297.47
| Professional | | $2,572.39 | $3,368.43 | $4,297.47 |
- 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
- $1,708.20 / $2,409.83 / $3,919.72
| Professional | | $1,708.20 | $2,409.83 | $3,919.72 |