- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,290.88 / $3,001.09 / $3,762.60
| Facility | | $1,290.88 | $3,001.09 | $3,762.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,290.88 / $1,614.85 / $3,270.22
| Professional | | $1,290.88 | $1,614.85 | $3,270.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,402.01 / $1,456.84 / $4,500.00
| Professional | | $1,402.01 | $1,456.84 | $4,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,427.10 / $2,774.09 / $4,278.72
| Professional | | $1,427.10 | $2,774.09 | $4,278.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,849.87 / $3,570.11 / $3,570.11
| Professional | | $2,849.87 | $3,570.11 | $3,570.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,261.00 / $4,165.00 / $26,408.00
| Facility | | $3,261.00 | $4,165.00 | $26,408.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,378.92 / $2,429.64 / $4,322.43
| Professional | | $1,378.92 | $2,429.64 | $4,322.43 |