- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $2,489.98 / $3,667.23
| Facility | | $1,277.00 | $2,489.98 | $3,667.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,847.61 / $2,489.98 / $3,257.31
| Professional | | $1,847.61 | $2,489.98 | $3,257.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,151.94 / $2,689.93 / $2,848.16
| Professional | | $2,151.94 | $2,689.93 | $2,848.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,245.98 / $3,284.98 / $3,791.88
| Professional | | $2,245.98 | $3,284.98 | $3,791.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,209.00 / $4,576.00 / $8,929.00
| Facility | | $2,209.00 | $4,576.00 | $8,929.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,932.28 / $2,859.79 / $4,115.41
| Professional | | $1,932.28 | $2,859.79 | $4,115.41 |