- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $2,602.01 / $4,637.07
| Facility | | $1,277.00 | $2,602.01 | $4,637.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,166.34 / $2,632.54 / $3,073.83
| Professional | | $2,166.34 | $2,632.54 | $3,073.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,097.60 / $2,776.23 / $2,776.23
| Professional | | $2,097.60 | $2,776.23 | $2,776.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,608.62 / $3,779.86 / $4,513.46
| Professional | | $2,608.62 | $3,779.86 | $4,513.46 |
- 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
- $2,051.48 / $2,697.51 / $4,407.85
| Professional | | $2,051.48 | $2,697.51 | $4,407.85 |