- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $2,477.00 / $9,034.00
| Facility | | $1,277.00 | $2,477.00 | $9,034.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,561.34 / $3,456.59 / $4,044.18
| Professional | | $2,561.34 | $3,456.59 | $4,044.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,981.92 / $3,727.39 / $3,946.65
| Professional | | $2,981.92 | $3,727.39 | $3,946.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,100.68 / $4,525.47 / $5,239.12
| Professional | | $3,100.68 | $4,525.47 | $5,239.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,565.00 / $2,667.00 / $6,957.00
| Facility | | $1,565.00 | $2,667.00 | $6,957.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,586.73 / $3,616.27 / $5,370.37
| Professional | | $2,586.73 | $3,616.27 | $5,370.37 |