- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $2,598.38 / $4,990.55
| Facility | | $1,277.00 | $2,598.38 | $4,990.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,569.54 / $3,693.09 / $3,693.09
| Professional | | $2,569.54 | $3,693.09 | $3,693.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,801.81 / $3,708.28 / $3,708.28
| Professional | | $2,801.81 | $3,708.28 | $3,708.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,540.67 / $3,988.87 / $5,254.88
| Professional | | $2,540.67 | $3,988.87 | $5,254.88 |
- 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
- $2,391.96 / $2,926.14 / $5,713.48
| Professional | | $2,391.96 | $2,926.14 | $5,713.48 |