- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $2,948.78 / $5,467.25
| Facility | | $1,277.00 | $2,948.78 | $5,467.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,490.52 / $3,063.68 / $3,760.65
| Professional | | $2,490.52 | $3,063.68 | $3,760.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,650.21 / $4,831.16 / $4,831.16
| Professional | | $3,650.21 | $4,831.16 | $4,831.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,330.00 / $4,403.18 / $5,576.42
| Professional | | $3,330.00 | $4,403.18 | $5,576.42 |
- 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
- $2,229.63 / $3,126.99 / $5,162.64
| Professional | | $2,229.63 | $3,126.99 | $5,162.64 |