- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,083.00 / $1,947.43 / $4,478.00
| Facility | | $1,083.00 | $1,947.43 | $4,478.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,419.51 / $2,012.06 / $2,259.21
| Professional | | $1,419.51 | $2,012.06 | $2,259.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,740.93 / $2,304.17 / $2,304.17
| Professional | | $1,740.93 | $2,304.17 | $2,304.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,930.38 / $2,724.53 / $3,075.10
| Professional | | $1,930.38 | $2,724.53 | $3,075.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,240.00 / $2,311.00 / $5,626.00
| Facility | | $1,240.00 | $2,311.00 | $5,626.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,424.53 / $1,917.25 / $3,268.05
| Professional | | $1,424.53 | $1,917.25 | $3,268.05 |