- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $2,067.31 / $8,907.65
| Facility | | $1,277.00 | $2,067.31 | $8,907.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,252.04 / $5,096.67 / $5,662.71
| Professional | | $2,252.04 | $5,096.67 | $5,662.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,020.30 / $5,320.98 / $5,320.98
| Professional | | $4,020.30 | $5,320.98 | $5,320.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,635.00 / $6,593.00 / $8,733.31
| Professional | | $2,635.00 | $6,593.00 | $8,733.31 |
- 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
- $1,706.09 / $3,844.36 / $8,416.00
| Professional | | $1,706.09 | $3,844.36 | $8,416.00 |