- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $2,918.42 / $6,546.90
| Facility | | $1,277.00 | $2,918.42 | $6,546.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,895.30 / $3,723.55 / $4,237.88
| Professional | | $2,895.30 | $3,723.55 | $4,237.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,955.27 / $3,911.38 / $3,911.38
| Professional | | $2,955.27 | $3,911.38 | $3,911.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,125.00 / $4,810.53 / $6,367.65
| Professional | | $3,125.00 | $4,810.53 | $6,367.65 |
- 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
- $2,604.94 / $3,311.68 / $6,185.66
| Professional | | $2,604.94 | $3,311.68 | $6,185.66 |