- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $2,711.76 / $4,469.34
| Facility | | $1,277.00 | $2,711.76 | $4,469.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,257.34 / $2,711.76 / $3,490.08
| Professional | | $2,257.34 | $2,711.76 | $3,490.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,536.13 / $3,356.64 / $3,356.64
| Professional | | $2,536.13 | $3,356.64 | $3,356.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,243.40 / $3,884.91 / $4,709.27
| Professional | | $2,243.40 | $3,884.91 | $4,709.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $375.00 / $1,230.00 / $2,421.00
| Facility | | $375.00 | $1,230.00 | $2,421.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,219.09 / $2,728.90 / $5,004.42
| Professional | | $2,219.09 | $2,728.90 | $5,004.42 |