- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $2,859.40 / $5,047.25
| Facility | | $1,277.00 | $2,859.40 | $5,047.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,350.90 / $2,861.33 / $3,533.07
| Professional | | $2,350.90 | $2,861.33 | $3,533.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,282.81 / $3,021.36 / $3,021.36
| Professional | | $2,282.81 | $3,021.36 | $3,021.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,774.97 / $4,080.44 / $4,915.00
| Professional | | $2,774.97 | $4,080.44 | $4,915.00 |
- 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
- $2,228.76 / $3,079.36 / $4,788.56
| Professional | | $2,228.76 | $3,079.36 | $4,788.56 |