- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $1,846.00 / $4,776.38
| Facility | | $1,277.00 | $1,846.00 | $4,776.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,062.64 / $2,651.14 / $3,034.99
| Professional | | $2,062.64 | $2,651.14 | $3,034.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,160.19 / $2,859.08 / $2,859.08
| Professional | | $2,160.19 | $2,859.08 | $2,859.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,083.87 / $3,395.68 / $4,159.20
| Professional | | $2,083.87 | $3,395.68 | $4,159.20 |
- 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
- $1,364.66 / $2,094.35 / $4,468.08
| Professional | | $1,364.66 | $2,094.35 | $4,468.08 |