- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $2,627.82 / $4,901.64
| Facility | | $1,277.00 | $2,627.82 | $4,901.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,251.46 / $2,741.15 / $3,367.16
| Professional | | $2,251.46 | $2,741.15 | $3,367.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,273.28 / $4,332.28 / $4,332.28
| Professional | | $3,273.28 | $4,332.28 | $4,332.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,640.00 / $3,944.49 / $4,986.39
| Professional | | $2,640.00 | $3,944.49 | $4,986.39 |
- 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
- $1,997.67 / $2,796.14 / $4,628.47
| Professional | | $1,997.67 | $2,796.14 | $4,628.47 |