- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,139.48 / $2,028.00 / $3,109.00
| Facility | | $1,139.48 | $2,028.00 | $3,109.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,549.64 / $1,835.67 / $2,348.02
| Professional | | $1,549.64 | $1,835.67 | $2,348.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,854.24 / $2,317.81 / $2,454.15
| Professional | | $1,854.24 | $2,317.81 | $2,454.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,270.00 / $2,498.44 / $3,256.71
| Professional | | $1,270.00 | $2,498.44 | $3,256.71 |
- 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
- $1,054.46 / $1,665.94 / $3,296.06
| Professional | | $1,054.46 | $1,665.94 | $3,296.06 |