- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $2,788.67 / $4,951.17
| Facility | | $1,277.00 | $2,788.67 | $4,951.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,310.16 / $2,809.47 / $3,202.55
| Professional | | $2,310.16 | $2,809.47 | $3,202.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,240.08 / $2,964.82 / $2,964.82
| Professional | | $2,240.08 | $2,964.82 | $2,964.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,785.24 / $4,005.07 / $4,870.00
| Professional | | $2,785.24 | $4,005.07 | $4,870.00 |
- 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
- $2,182.08 / $2,505.78 / $4,688.00
| Professional | | $2,182.08 | $2,505.78 | $4,688.00 |