- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $2,193.84 / $3,361.44
| Facility | | $1,277.00 | $2,193.84 | $3,361.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,627.27 / $2,193.84 / $2,869.71
| Professional | | $1,627.27 | $2,193.84 | $2,869.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,910.43 / $2,388.04 / $2,528.51
| Professional | | $1,910.43 | $2,388.04 | $2,528.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,969.07 / $2,931.55 / $3,360.52
| Professional | | $1,969.07 | $2,931.55 | $3,360.52 |
- 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
- $1,686.88 / $2,511.69 / $3,663.78
| Professional | | $1,686.88 | $2,511.69 | $3,663.78 |