- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $3,024.07 / $6,713.60
| Facility | | $1,277.00 | $3,024.07 | $6,713.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,968.70 / $3,825.96 / $4,267.21
| Professional | | $2,968.70 | $3,825.96 | $4,267.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,030.20 / $4,010.55 / $4,010.55
| Professional | | $3,030.20 | $4,010.55 | $4,010.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,767.09 / $4,937.93 / $6,540.15
| Professional | | $3,767.09 | $4,937.93 | $6,540.15 |
- 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
- $2,640.90 / $3,301.12 / $6,343.88
| Professional | | $2,640.90 | $3,301.12 | $6,343.88 |