- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $3,030.34 / $5,020.60
| Facility | | $1,277.00 | $3,030.34 | $5,020.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,759.14 / $3,755.22 / $3,755.22
| Professional | | $2,759.14 | $3,755.22 | $3,755.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,860.47 / $3,785.91 / $3,785.91
| Professional | | $2,860.47 | $3,785.91 | $3,785.91 |
- 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
- $2,317.75 / $3,015.65 / $5,397.71
| Professional | | $2,317.75 | $3,015.65 | $5,397.71 |