- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $2,445.78 / $5,227.72
| Facility | | $1,277.00 | $2,445.78 | $5,227.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,307.94 / $2,958.82 / $3,327.59
| Professional | | $2,307.94 | $2,958.82 | $3,327.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,365.46 / $3,130.76 / $3,130.76
| Professional | | $2,365.46 | $3,130.76 | $3,130.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,895.00 / $3,838.26 / $5,073.35
| Professional | | $2,895.00 | $3,838.26 | $5,073.35 |
- 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
- $1,960.16 / $2,460.73 / $4,948.37
| Professional | | $1,960.16 | $2,460.73 | $4,948.37 |