- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $2,493.00 / $5,848.77
| Facility | | $1,277.00 | $2,493.00 | $5,848.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,564.11 / $3,312.93 / $3,719.49
| Professional | | $2,564.11 | $3,312.93 | $3,719.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,648.11 / $3,504.85 / $3,504.85
| Professional | | $2,648.11 | $3,504.85 | $3,504.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,945.00 / $4,274.67 / $5,676.85
| Professional | | $2,945.00 | $4,274.67 | $5,676.85 |
- 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
- $2,137.71 / $2,820.44 / $5,539.70
| Professional | | $2,137.71 | $2,820.44 | $5,539.70 |