- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $2,201.42 / $4,023.20
| Facility | | $1,277.00 | $2,201.42 | $4,023.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,836.91 / $2,244.67 / $2,756.32
| Professional | | $1,836.91 | $2,244.67 | $2,756.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,687.65 / $3,557.18 / $3,557.18
| Professional | | $2,687.65 | $3,557.18 | $3,557.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,468.46 / $3,292.76 / $4,077.57
| Professional | | $2,468.46 | $3,292.76 | $4,077.57 |
- 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
- $1,620.80 / $2,197.23 / $3,665.61
| Professional | | $1,620.80 | $2,197.23 | $3,665.61 |