- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $2,410.28 / $3,829.29
| Facility | | $1,277.00 | $2,410.28 | $3,829.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,962.33 / $2,410.28 / $2,987.37
| Professional | | $1,962.33 | $2,410.28 | $2,987.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,151.04 / $2,846.97 / $2,846.97
| Professional | | $2,151.04 | $2,846.97 | $2,846.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,533.06 / $3,385.22 / $4,139.45
| Professional | | $2,533.06 | $3,385.22 | $4,139.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,565.00 / $2,828.00 / $6,957.00
| Facility | | $1,565.00 | $2,828.00 | $6,957.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.76 / $2,293.13 / $4,145.14
| Professional | | $1,862.76 | $2,293.13 | $4,145.14 |