- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $2,652.65 / $4,855.89
| Facility | | $1,277.00 | $2,652.65 | $4,855.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,254.04 / $2,747.77 / $3,280.17
| Professional | | $2,254.04 | $2,747.77 | $3,280.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,197.66 / $2,908.67 / $2,908.67
| Professional | | $2,197.66 | $2,908.67 | $2,908.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,724.79 / $3,719.81 / $4,713.25
| Professional | | $2,724.79 | $3,719.81 | $4,713.25 |
- 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
- $2,072.26 / $2,814.74 / $4,597.32
| Professional | | $2,072.26 | $2,814.74 | $4,597.32 |