- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $2,493.98 / $3,629.83
| Facility | | $1,277.00 | $2,493.98 | $3,629.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,802.75 / $2,493.98 / $3,262.20
| Professional | | $1,802.75 | $2,493.98 | $3,262.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,156.42 / $2,695.53 / $2,854.09
| Professional | | $2,156.42 | $2,695.53 | $2,854.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,249.59 / $3,290.27 / $3,798.40
| Professional | | $2,249.59 | $3,290.27 | $3,798.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,104.00 / $4,334.00 / $8,676.00
| Facility | | $2,104.00 | $4,334.00 | $8,676.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,921.73 / $2,774.97 / $4,158.22
| Professional | | $1,921.73 | $2,774.97 | $4,158.22 |