- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $2,541.38 / $5,104.64
| Facility | | $1,277.00 | $2,541.38 | $5,104.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,152.06 / $2,838.62 / $3,498.17
| Professional | | $2,152.06 | $2,838.62 | $3,498.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,409.37 / $4,512.39 / $4,512.39
| Professional | | $3,409.37 | $4,512.39 | $4,512.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,026.11 / $3,955.21 / $5,171.24
| Professional | | $3,026.11 | $3,955.21 | $5,171.24 |
- 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
- $1,997.34 / $2,692.20 / $4,648.77
| Professional | | $1,997.34 | $2,692.20 | $4,648.77 |