- 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
- $2,483.87 / $3,432.60 / $4,049.83
| Professional | | $2,483.87 | $3,432.60 | $4,049.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,980.50 / $3,725.63 / $3,944.78
| Professional | | $2,980.50 | $3,725.63 | $3,944.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,062.45 / $4,460.87 / $5,244.75
| Professional | | $3,062.45 | $4,460.87 | $5,244.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,565.00 / $2,828.00 / $6,957.00
| Facility | | $1,565.00 | $2,828.00 | $6,957.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,574.32 / $3,817.54 / $5,336.23
| Professional | | $2,574.32 | $3,817.54 | $5,336.23 |