- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $2,607.81 / $4,625.43
| Facility | | $1,277.00 | $2,607.81 | $4,625.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,032.58 / $2,607.81 / $3,103.29
| Professional | | $2,032.58 | $2,607.81 | $3,103.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,093.00 / $2,770.15 / $2,770.15
| Professional | | $2,093.00 | $2,770.15 | $2,770.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,546.28 / $3,741.65 / $4,565.00
| Professional | | $2,546.28 | $3,741.65 | $4,565.00 |
- 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
- $1,967.08 / $2,845.07 / $4,366.22
| Professional | | $1,967.08 | $2,845.07 | $4,366.22 |