- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $2,489.59 / $4,571.22
| Facility | | $1,277.00 | $2,489.59 | $4,571.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,108.94 / $2,552.53 / $3,137.12
| Professional | | $2,108.94 | $2,552.53 | $3,137.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,052.63 / $4,040.24 / $4,040.24
| Professional | | $3,052.63 | $4,040.24 | $4,040.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,800.16 / $3,669.14 / $4,643.32
| Professional | | $2,800.16 | $3,669.14 | $4,643.32 |
- 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
- $1,845.67 / $2,597.73 / $4,314.95
| Professional | | $1,845.67 | $2,597.73 | $4,314.95 |