- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $2,685.27 / $5,011.92
| Facility | | $1,277.00 | $2,685.27 | $5,011.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,319.86 / $2,804.52 / $3,445.05
| Professional | | $2,319.86 | $2,804.52 | $3,445.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,346.89 / $4,429.71 / $4,429.71
| Professional | | $3,346.89 | $4,429.71 | $4,429.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,845.00 / $4,060.10 / $5,102.58
| Professional | | $2,845.00 | $4,060.10 | $5,102.58 |
- 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
- $2,042.11 / $2,532.07 / $4,587.05
| Professional | | $2,042.11 | $2,532.07 | $4,587.05 |