- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $2,236.27 / $3,556.20
| Facility | | $1,277.00 | $2,236.27 | $3,556.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,794.93 / $2,236.27 / $2,757.15
| Professional | | $1,794.93 | $2,236.27 | $2,757.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,998.51 / $2,645.08 / $2,645.08
| Professional | | $1,998.51 | $2,645.08 | $2,645.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,350.96 / $3,143.81 / $3,842.72
| Professional | | $2,350.96 | $3,143.81 | $3,842.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,565.00 / $2,828.00 / $6,992.00
| Facility | | $1,565.00 | $2,828.00 | $6,992.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,729.22 / $2,193.54 / $3,848.00
| Professional | | $1,729.22 | $2,193.54 | $3,848.00 |