- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $2,659.82 / $4,665.89
| Facility | | $1,277.00 | $2,659.82 | $4,665.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,123.21 / $2,659.82 / $3,310.23
| Professional | | $2,123.21 | $2,659.82 | $3,310.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,103.34 / $2,783.84 / $2,783.84
| Professional | | $2,103.34 | $2,783.84 | $2,783.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,601.65 / $3,687.23 / $4,556.84
| Professional | | $2,601.65 | $3,687.23 | $4,556.84 |
- 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
- $2,037.91 / $2,722.53 / $4,417.38
| Professional | | $2,037.91 | $2,722.53 | $4,417.38 |