- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $2,214.27 / $4,037.52
| Facility | | $1,277.00 | $2,214.27 | $4,037.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,866.47 / $2,260.57 / $2,770.05
| Professional | | $1,866.47 | $2,260.57 | $2,770.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,696.57 / $3,569.00 / $3,569.00
| Professional | | $2,696.57 | $3,569.00 | $3,569.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,435.00 / $3,266.02 / $4,103.89
| Professional | | $2,435.00 | $3,266.02 | $4,103.89 |
- 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
- $1,615.01 / $2,301.27 / $3,750.89
| Professional | | $1,615.01 | $2,301.27 | $3,750.89 |