- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $2,806.73 / $5,574.20
| Facility | | $1,277.00 | $2,806.73 | $5,574.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,447.21 / $3,167.30 / $3,719.88
| Professional | | $2,447.21 | $3,167.30 | $3,719.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,516.58 / $3,330.77 / $3,330.77
| Professional | | $2,516.58 | $3,330.77 | $3,330.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,128.59 / $4,301.45 / $5,404.72
| Professional | | $3,128.59 | $4,301.45 | $5,404.72 |
- 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
- $2,363.56 / $2,836.28 / $5,265.62
| Professional | | $2,363.56 | $2,836.28 | $5,265.62 |