- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $2,495.28 / $4,649.55
| Facility | | $1,277.00 | $2,495.28 | $4,649.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,146.48 / $2,598.23 / $3,193.15
| Professional | | $2,146.48 | $2,598.23 | $3,193.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,105.62 / $4,110.38 / $4,110.38
| Professional | | $3,105.62 | $4,110.38 | $4,110.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,715.00 / $3,700.86 / $4,726.14
| Professional | | $2,715.00 | $3,700.86 | $4,726.14 |
- 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
- $1,949.68 / $2,372.96 / $4,248.64
| Professional | | $1,949.68 | $2,372.96 | $4,248.64 |