- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,342.00 / $2,447.94 / $3,671.91
| Facility | | $1,342.00 | $2,447.94 | $3,671.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.28 / $2,447.94 / $2,913.05
| Professional | | $1,905.28 | $2,447.94 | $2,913.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,313.31 / $2,891.64 / $3,061.74
| Professional | | $2,313.31 | $2,891.64 | $3,061.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,118.29 / $3,200.46 / $4,043.88
| Professional | | $2,118.29 | $3,200.46 | $4,043.88 |
- 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
- $1,880.77 / $2,434.06 / $4,083.34
| Professional | | $1,880.77 | $2,434.06 | $4,083.34 |