- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $2,561.04 / $4,280.71
| Facility | | $1,277.00 | $2,561.04 | $4,280.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,193.29 / $3,156.09 / $3,156.09
| Professional | | $2,193.29 | $3,156.09 | $3,156.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,403.71 / $3,181.38 / $3,181.38
| Professional | | $2,403.71 | $3,181.38 | $3,181.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,160.57 / $3,415.09 / $4,504.17
| Professional | | $2,160.57 | $3,415.09 | $4,504.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $375.00 / $1,056.00 / $2,558.00
| Facility | | $375.00 | $1,056.00 | $2,558.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,091.51 / $2,532.28 / $4,548.12
| Professional | | $2,091.51 | $2,532.28 | $4,548.12 |