- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $2,292.46 / $4,026.77
| Facility | | $1,277.00 | $2,292.46 | $4,026.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,034.76 / $2,292.46 / $2,888.09
| Professional | | $2,034.76 | $2,292.46 | $2,888.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,815.13 / $2,402.38 / $2,402.38
| Professional | | $1,815.13 | $2,402.38 | $2,402.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,252.66 / $3,326.18 / $3,927.41
| Professional | | $2,252.66 | $3,326.18 | $3,927.41 |
- 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
- $1,784.81 / $2,499.27 / $3,812.34
| Professional | | $1,784.81 | $2,499.27 | $3,812.34 |