- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,342.00 / $2,443.08 / $3,664.62
| Facility | | $1,342.00 | $2,443.08 | $3,664.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,827.17 / $2,300.38 / $2,711.53
| Professional | | $1,827.17 | $2,300.38 | $2,711.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,115.31 / $2,644.14 / $2,799.68
| Professional | | $2,115.31 | $2,644.14 | $2,799.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,910.58 / $2,933.77 / $3,699.68
| Professional | | $1,910.58 | $2,933.77 | $3,699.68 |
- 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
- $1,775.21 / $2,476.57 / $4,014.83
| Professional | | $1,775.21 | $2,476.57 | $4,014.83 |